As the COVID-19 continues to swiftly evolve into a full-blown pandemic, Lebanon is planning to initiate the first round of immunization within the first quarter of this year, slated HCWs and the elderly to be an early recipient of the COVID-19 vaccine. Since HCWs are at high occupational risk for COVID-19 and will be responsible to administer and recommend vaccines to their patients and the general population, hence the importance of gauging their willingness to get vaccinated and to identify the determinants of their COVID-19 vaccine acceptance. Besides, it allows us to proactively develop the appropriate interventions, particularly during the current flood of misinformation about the safety of the vaccine. To the best of our knowledge, this is the first large national study investigating both determinants of COVID-19 vaccine uptake among HCWs as well as their willingness to get the vaccine.
Our findings showed that 20.9% of surveyed HCWs reported a personal history of COVID-19 infection and 91.9% of them had a colleague infected by COVID-19. However, this infectiousness rate among Lebanese HCWs was higher than the reported rate in Qatar, where a study conducted among 16,912 HCWs revealed that10.6% of HCWs were positive for COVID-19 and an exposure to a colleague (45%) or a patient was stated [25]. In India, a study reported an 11% prevalence of COVID-19 infection among HCWs [26]. This could be due to the lack of sufficient personal protective equipment (PPEs) at facilities, their proper use and poor adherence to other infection control measures. Therefore, our results underline the need of effective HCWs protection.
More than half of our participants were working in the frontline of the response to COVID-19. Since many studies emphasized a significant amplified risk of COVID-19 infection among frontliners who are in direct contact with COVID-19 patients compared to the general community [27], there is an urgent need to improve the acceptance of COVID-19 vaccine particularly among this category.
The study’s main findings are that nearly 58% of surveyed participants were willing to receive the COVID-19 vaccine. Our results were consistent with the findings displayed in a systematic review regarding acceptability of COVID-19 vaccine which found that the proportion of HCWs that intent to accept COVID-19 vaccination was 55.9% with a wide range among studies from 27.7% to 81.5%. In United States of America (USA), a recent preprint research paper reports that vaccine acceptance is low even among HCWs [28]. This willingness to get vaccinated increased with age. Our results are concordant with those of a study conducted in DR Congo among HCWs [29]. An increase of acceptance of vaccine among older HCWs may be due to the fear expressed by elderly, given the serious complications and deaths recorded amongst them. Geographical variation in vaccine acceptance was also found in our survey. Peripheral areas such as Akkar province had the lowest acceptance rate comparing to the capital (Beirut).
One noteworthy finding in the present study is that influenza vaccination coverage during the current season escalates to 67.3% comparing to the past season where only 45.4% of surveyed HCWs have received their influenza vaccine. This could be due to the fact that public health experts highlight the importance of influenza vaccine during the COVID-19 pandemic which overlapped with the influenza season. It is also indicating a generally promising perception of vaccination. However, only 18.94% of them had reported that they have previous experience of refusal of a type of vaccine other than influenza. This behavior defined as vaccine hesitancy could be related to confidence issues, complacency and convenience [30].
Concerning HCWs’ perception of susceptibility, the majority of participants perceived themselves susceptible to get COVID-19 due to their occupational exposure. A risk perception assessment of COVID-19 among Portuguese HCWs showed that 54.9% perceived themselves at a high likelihood of becoming infected [31]. Another study conducted in USA showed that HCWs, particularly nurses, have a higher prevalence of SARS-CoV-2 infection than non-health care workers, according to researchers at Rutgers [32].
Notably, 91.6% of HCWs considered that healthy people can get COVID-19 infection and could need hospitalization. These findings were in line with the outcomes of a study conducted among more than 3,000 adults aged between 18 and 34 years who contracted COVID-19 and required hospitalization. Researchers reported that 21% of them ended up in intensive care, 10% were placed on a breathing machine and 2.7% died [33] On the other hand, only half of them declared that they can protect themselves better than other people. One possible explanation could be that this proportion of HCWs consider themselves more aware and knowledgeable of the latest information of COVID-19 pandemic. Their skills, received training and their adherence to basic infection prevention measures such as basic hygiene (hand and cough etiquette), the availability and adequate use of protective personal equipment make them feeling safer and more protected against infectious diseases. Indeed, HCWs were mentioned as the ‘canary in the mine’.
More than 90% of HCWs agreed that COVID-19 makes some people ill and could be fatal and 85.6% considered it more serious than influenza [34]. In this regard, many health experts highlighted the large numbers of susceptible people due to the slight preexistent immunity to the virus that causes COVID-19 infection which allows it to blowout so easily and increasing rates of severe disease and deaths.
Only 29.3% of them thought that they will be very ill if they contracted COVID-19, 30.7% stated that they may need hospitalization and 21.7% pondered that they might die. Our results were consistent with the findings of a study conducted in China, which revealed that the proportion of HCWs with severe illness was high in early January 2020 then decreased reflecting more steady adoption of IPC [35]. However, severe illness among HCWs continues to be reported, suggesting that the use of currently approved infection control processes do not entirely prevent severe COVID-19 among HCWs.
Our participants mentioned that the main benefits of getting vaccinated against COVID-19 include decreasing their fears about catching COVID-19, decreasing their chance of getting infected or presenting complications, protecting their patients and family members and preventing the spread of COVID-19 at community level. This comes in consistency with the findings of a study conducted among Chinese population who perceived the same benefits [36].
The main barriers cited by HCW’s that could hamper their willingness to vaccinate against COVID-19 were their concerns about novelty, side effects, efficacy, and the vaccine safety. There are vigorous testing trials in place to warrant that approved COVID-19 vaccines are both effective and safe [37]. Bearing in mind that all kind of therapies, including vaccination, has risks. Addressing the extent of those risks presents a biggest challenge in the development of the COVID-19 vaccine .
In terms of gender, our results also revealed some interesting results, males were 2 times more likely to get vaccinated compared to males. Our results were consistent with other studies that showed that men were more willing to get vaccinated compared to women. This could be explained by the high infection rate of COVID-19 among them. A study conducted among Newzeelanders showed that two-thirds of women were willing to be vaccinated compared to three-quarters of men [38].
Besides, working in the frontline was associated positively to vaccine acceptance; this may be due to the highest risk of susceptibility faced by this category of HCWs. Our results were in line with a study conducted in USA that found that vaccine acceptance was higher among HCWs involved in direct patient care [39]. It is worth mentioning that past behavior handed over by receiving influenza vaccination in the current season was positively associated with the COVID-19 vaccine acceptance.
Having personal history of COVID-19 infection was negatively associated with the willingness to vaccinate, this could be due to the fact that the majority of previously infected people considered themselves as naturally immune, hence they refused to get vaccinated.
The majority of the HBM domains were considerably associated with the vaccine uptake. In particular, respondents who perceived the vaccine as conferring benefits, and received cues to action were significantly more likely to accept the vaccine. Our results were consistent with the outcomes of a study conducted in China [40].
Of note, we found that some keys components of HBM such us perceived susceptibility and perceived severity of infection were not associated with the vaccine acceptance. This observation could be explained by the fact that COVID-19 is perceived as a mild disease unless the infected person has underlying risk conditions. This implies the direction of promotion and education for COVID-19 vaccine should be different than other vaccines in which prevention of infection is perceived as the main purpose.
On the other hand, perceived barriers such as novelty of vaccine, possible side effects induced by the vaccine,reliability of manufacturer, trust of the source and number of doses required to get immune were negatively associated with the vaccine uptake. Our results were in line with the facts that trust in vaccination manufacturer and source contributes to explain vaccination uptake [41]. Given the massive plea of COVID 19 vaccine, a large number of new companies entered to the market [42]. However, the lack of awareness besides the large number of suppliers at once would intensify the doubt of vaccine recipients towards the validity of less recognized producers, which may in turn limit their acceptance of vaccines. In order to crack this obstacle, governments should also proactively include details about their chosen vaccine manufacturer(s). A peculiar finding that HCWs who conceived limited availability and accessibility of COVID-19 vaccine as barriers were more likely to accept vaccine. This could be explained by the facts that were usually the unreachable makes things unspeakably desirable. However, it is not universal human nature but a common learned pattern.
The main predictor of the willingness to vaccinate was the perception of benefits, HCWs who perceived the benefits were 10.771 more likely to get vaccinated than their counterparts with low perception of benefits. Our results were concordant with a study conducted in France that stresses the importance of communicating the benefits of herd immunity in reducing COVID-19 vaccine hesitancy [43].
With regards to cues of action, we found a remarkable pattern for COVID-19 vaccine. The recommendation from the health authorities and from the health facilities stood out as the most important cues. However, family members’ recommendation that is associated negatively to COVID-19 vaccine associated with acceptance. A substantial discrepancy was recorded by country, with China again having the highest proportion of positive responses (83.7%) comparing to Russia that had the highest proportion of negative responses willing to accept their employer’s recommendation [44].
Furthermore, having reliable, sufficient and adequate information regarding the vaccine also turn out to be an important driver of vaccine acceptance. These observations highlight evidence-based design of vaccine promotion campaigns tailored for the context of the HCWs concern.
Consistently to other studies that demonstrated the capability of the HBM constructs in predicting behaviors related to influenza vaccination [45]. Our findings suggested that the domains of HBM could be used to elucidate vaccine uptake behavior.
In summary, this study revealed a moderate acceptance rate of COVID-19 vaccine among participated HCWs and this could have broader extents. Our findings highlighted also the significance of governmental and facility recommendation on vaccine uptake, whereas knowledge, perceived susceptibility and severity to infection were not. Acceptance could be impaired by worries on novel vaccination approaches and manufacturers reliability. It will also guide us to develop the appropriate interventions to increase COVID-19 vaccination uptake.
There is a significant need for addressing concerns and increasing awareness to improve acceptance rate for COVID-19 vaccine. Otherwise, there is an additional chance of mass hesitancy among the general population when the COVID-19 vaccine becomes available.
Limitations of the study:
Several limitations of this study should be acknowledged. Firstly, this is a cross-sectional survey and we could not establish a cause-and-effect relationship between the independent factors and the outcome. They could however be used in prediction of COVID-19 vaccine acceptance. Also, this survey examined the HBM constructs among Lebanese HCWs, and the generalizability of its findings to other settings should be cautious. Secondly, our study relies on HCWs self-reported information, which may be a threat to information bias. In addition, self-reported information could be associated with recall bias about past behaviors. On other hand, participant’s responses may be influenced by social desirability and then intentionally modified to meet the norms. Finally, since the online survey relies on the availability and accessibility to internet, there is a possibility of selection bias.