key: cord-0697410-p4x7ibwn
authors: Ye, X.; Ye, W.; Yu, J.; Gao, Y.; Ren, Z.; Chen, L.; Dong, A.; Yi, Q.; Zhan, C.; Lin, Y.; Wang, Y.; Huang, S.; Song, P.
title: Factors Associated with the Acceptance and Willingness of COVID-19 Vaccination among Chinese Healthcare Workers
date: 2021-05-17
journal: nan
DOI: 10.1101/2021.05.15.21257094
sha: d59059f8d21d101a663b021ae3b2798257c92836
doc_id: 697410
cord_uid: p4x7ibwn

Background: Vaccination is a crucial measure in preventing the spread of epidemic. Vaccines targeting coronavirus disease 2019 (COVID-19) have been developed in a wide range of countries. Objective: This study aims to examine factors influencing vaccination rate and willingness to vaccinate against COVID-19 among Chinese healthcare workers (HCWs). Methods: From 3rd February to 18th February, 2021, an online cross-sectional survey was conducted among HCWs to investigate factors associated with the acceptance and willingness of COVID-19 vaccination. Respondents were classified into two categories, vaccinated and unvaccinated, and, the willingness of vaccination was assessed in the unvaccinated group. Information on socio-demographics and the psychological process of the participants for accepting the vaccine were evaluated. Results: A total of 2156 HCWs from 21 provinces in China responded to this survey (response rate: 98.99%)), among whom 1433 (66.5%) were vaccinated at least one dose. Higher vaccination rates were associated with older age (40-50 years vs. less than 30 years, OR=1.63, 95%CI: 1.02-2.58; >50 years vs. 30 years, OR=1.90, 95%CI: 1.02-3.52), working as a clinician (OR=1.54, 95% CI: 1.05-2.27), having no personal religion (OR=1.35, 95%CI: 1.06-1.71), working in a fever clinic (OR=4.50 , 95%CI:1.54-13.17) or higher hospital level(Municipal vs. County, OR=2.01, 95%CI: 1.28-3.16; Provincial vs. County, OR=2.01, 95%CI: 1.25-3.22) and having knowledge training of vaccine (OR=1.67, 95%CI:1.27-2.22), family history for influenza vaccination (OR=1.887, 95%CI:1.49-2.35) and strong familiarity with the vaccine (OR=1.43, 95%CI:1.05-1.95) (All P<0.05). Strong willingness for vaccination was related to having a working in midwestern China (OR=1.89, 95%CI:1.24-2.89), considerable knowledge of the vaccine (familiar vs. not familiar, OR=1.67, 95%CI: 1.17-2.39; strongly familiar vs. not familiar, OR=2.47, 95%CI: 1.36-4.49), knowledge training of vaccine(OR=1.61, 95%CI: 1.05-2.48) and strong confidence in the vaccine (OR=3.84 , 95%CI: 2.09-7.07). Conclusion: Personal characteristics, working environments, familiarity and confidence in the vaccine were related to vaccination rates and willingness to get vaccinated among healthcare workers. Results of this study could provide evidence for the government to improve vaccine coverage by addressing vaccine hesitancy in the COVID-19 pandemic and future public health emergencies.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, emerged in late 2019 and has caused a global pandemic. The pandemic has led to more than 90 million cases and 1.9 million deaths worldwide, with disastrous consequences for the world economy and public health. 1 To achieve herd immunity and finally end the pandemic, 60 to 70% of the world population were suggested to be immune, either though natural infection or vaccination. 2 Vaccination is one of the most effective health interventions to prevent and control the spread of infectious diseases. 1, 3 Safe and effective vaccines against SARS-CoV-2 are necessary to protect populations from COVID-19 and to safeguard global economies from continued disruption. 3, 4 The first human clinical trial of a SARS-CoV-2 vaccine (mRNA-1273) commenced on March 2020 in the United States, 5 and a 94.1% efficacy of this vaccine has been confirmed. 6, 7 However, the global uptake of the SARS-CoV-2 vaccine remains insufficient for herd immunity. 8, 9 To date (1 st April 2021), nearly 127 million doses of SARS-CoV-2 vaccine have been administered in China, which is only about 9% of the adult population. 10 Meanwhile, some high-risk, low-income countries, such as Afghanistan, Ethiopia, and Guinea, have not even released vaccination data. 11 One of the reasons for the vaccine hesitancy may be the doubt about its effectiveness and safety; a survey in the United States showed that 31% of adults were not willing to get the vaccine due to a fear of side effects, 12 and another study in France reported the 26% of adults felt resistance toward receiving the vaccine due to doubts of its effectiveness. 13 Furthermore, a survey in China indicates the gap between people's willingness to accept the vaccine and their actual vaccinating activity; about 47.8% of participants expressed "willingness" to receive the vaccine, but they will postpone vaccination until the safety of the vaccine is confirmed. 14 Healthcare workers (HCWs) are high-risk groups during the COVID-19 pandemic. 15, 16 The infection risk for this group is 9-11 times higher than that of the general population. 17 Once HCWs are infected, the infection risk for patients can consequently increase. Hence, understanding the willingness of HCWs to accept the SARS-CoV-2 vaccine and exploring the determinants for vaccinating action can help formulate targeted education and vaccine-promoting policies, which is of great importance in enhancing vaccine uptake and avoiding future outbreaks. Much of the existing literature either focuses on evaluating the explicit reasons for vaccine hesitance and resistance, 5, 18, 19 or investigates the relationship between vaccination intention and sociodemographic factors of the general public by using health belief theory or planning behavior theory. [20] [21] [22] [23] There is a number of investigations identifying the psychological processes of people's decision to be vaccinated and distinguishing them from those who have the intention but will not take action.

The multiple health locus of control (MHLC) scale was developed to investigate one's beliefs that the source of reinforcements for their health-related behaviors is primarily internal (determined by their own opinion) or external (determined by a matter of chance, or under the control of powerful persons). 24 Nowadays, the scale has been used as one of the most efficient measures for health-related behaviors. [25] [26] [27] The present study aims to use this measurement to investigate whether the decision for accepting the COVID-19 vaccine is controlled by internal or external factors in HCWs. This study also evaluated factors influencing actual vaccination rate and willingness among HCWs in China. Results can be used to make further recommendations for corresponding vaccination strategies and immunization plans, which are of particular importance in increasing the vaccine coverage.

The inclusion criteria for this study were: (1) age ≥ 18 years old; and (2) hospital HCWs, including any doctors and nurses who worked full time at public hospitals or local clinics. All respondents gave informed consent and voluntarily participated in the survey. The exclusion criteria included (1) interns, student nurses, and medical students in school; and (2) individuals who were employed by private hospitals.

The questionnaire contained the following three parts: demographics, vaccination-related intentions and behaviors, and the MHLC scales:

(1) Demographic information (13 items): participants' gender, age, education background, religion, income, living area, field of work, time of employment, clinical occupation, and level of the hospital.

(2) COVID-19 vaccination-related features: vaccination status, willingness to vaccinate, and vaccine-related knowledge.

(3) The MHLC scale: The scale consists of three parts, including the internal health locus of control (IHLC, beliefs that health outcomes are related to one's own ability and effort, Cronbach =0.61-0.80), powerful other's health locus of control (PHLC, beliefs that health outcomes are related to powerful others such as physicians, Cronbach =0.56-0.75), and chance health locus of control (CHLC, beliefs that health outcomes are related to chance and fate, Cronbach =0.55-0.83). 24, 27, 28 Each part has six items (score range: 6-36), and a higher score represents a higher locus of control. 24 

This data collection was conducted from 3 rd to 18 th February, 2021, using a one-time anonymous online questionnaire. A pre-survey was conducted by selecting ten health professionals from different hospitals to finalize the questionnaire. The questionnaire was distributed by invitation through the social media group. Instructions were clearly provided and each questionnaire was completed with the assistance of a trained nurse. Each hospital has one or two training officers for questionnaire distribution and data collection. Details are shown in Figure S1 in Appendix 1.

Statistical analysis was performed using the R Foundation for Statistical Computing (version 4.0.3). Continuous variables were reported as mean and standard deviation (SD). Dichotomous . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 17, 2021. data were presented as frequency (%) and compared by Chi-square or Fisher's exact test in two groups. Univariate and multivariate logistic regression analyses were performed to determine independent risk factors. Multivariate analysis data were represented on a forest plot for all comparative odds ratio (OR) values with 95% confidence interval (CI). P values less than 0.05 were considered statistically significant. The bar plots of some potentially related reasons were presented to analyze differences among groups. Main packages including "forest plot," "glm," "ggolot2," "maps," "map data," and "tableone" were applied to visualize and analyze the results and make conclusions.

Between 3 rd February and 18 th February, 2021, a total of 2178 HCWs were recruited from 21 provinces across China, including 343 doctors and 1814 nurses. After removing 22 invalid questionnaires, 2156 were finally enrolled for data analysis (effective response rate: 98.99%).

A total of 1433 participants were vaccinated (66.5%). Individuals were categorized as vaccinated if they had been vaccinated at least one time at the completion of the survey ( Table   1 Figure S2 in Appendix 2).

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 17, 2021. ; . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) 

To detect whether accepting the vaccine was influenced by internal or external factors, the MHLC scale was adopted. No significant difference was found in IHLC and PHLC between vaccinated and unvaccinated populations. However, the PHLC score positively related to vaccination intention in the study population (as shown in Figure S3 in Appendix 4), reflecting that subjects' willingness to accept the vaccine may mainly be influenced by 

Based on the results of the MHLC, univariate and multivariate logistic regression analyses were conducted to explore factors influencing the acceptance of vaccines in HCWs ( Table S2 in Appendix 5 and Figure 1) . The unvaccinated population was divided into two groups: willingness (individuals who chose "strong willingness" or "relatively strong willingness" for accepting the vaccine) and not willingness groups (individuals who chose "moderate willingness," "unwillingness," and "very unwillingness" for vaccination).

As shown in Figure 1 , the vaccination willingness was significantly higher if the HCWs were working in midwestern China, had been trained with the knowledge of vaccines, had strong familiarity with vaccines, had more confidence in vaccines, and had healthy physical condition. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 17, 2021. ; https://doi.org/10.1101/2021.05.15.21257094 doi: medRxiv preprint also positively associated with higher vaccination rates among the HCWs (Table S2 in Appendix 5 and Figure 1 ).

To better understand the actual concerns of HCWs and to improve their willingness to vaccinate, subjective reasons related to COVID-19 vaccination were explored in the study population. Figure 2 shows the main reasons why HCWs would accept the vaccine, and, the top five reasons were: they are part of a high-risk group that needs to be vaccinated; they feel responsibility for reducing COVID-19 cases; they want to support national vaccine management; it is a recommendation by the government; safety and effectiveness of the vaccine.

Of the 1433 people that have been vaccinated, 673 (47.0%) had one dose and 760 (53.0%) had two doses; 1422 (99.2%) chose a domestic vaccine and 11 (0.8%) chose an imported vaccine.

A total of 135 adverse effects (9.4%) were reported, including weakness (74, 5.2%) and headache/dizziness (58, 4.0%) (Figure 3 ).

This study firstly provides an in-depth analysis of determinants for vaccination acceptance among HCWs from 21 provinces in China. Of the 2156 participants we included; the vaccination rate was 66.5%. A higher vaccination rate was associated with personal characteristics (male participant, older age, work as clinician, no personal religion, bachelor degree and higher, and healthy physical condition), working environment (longer years of clinical work, working in midwestern China, working in a fever clinic), and more familiarity and belief in the vaccine. Of the 723 unvaccinated participants, 10.9% were unwilling or very unwilling to receive the vaccination. Strong willingness to take the vaccine was related to having a healthy physical condition, considerable knowledge of the vaccine, and strong . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Moreover, the results show that the willingness to vaccinate was stronger in HCWs from midwestern regions than those from eastern regions. Considering that the vaccines are equally and sufficiently distributed in each province across the country, 33 this difference might reflect the comparatively weaker healthcare system in the midwestern regions of China; 34 specifically, people working in the midwest may be more worried about the result if they are infected, and, consequently, are more willing to be vaccinated. While acceptance of the vaccine was associated with the working location, the imbalanced acceptance rate across the country might be due to the imbalance of medical resources in different regions of China, 35 reflecting that efficient delivery of high-quality healthcare to each province is vital for China's future medical development.

Interestingly, it was found that self-reported willingness to receive the vaccine may not correlated with taking the vaccine. Whilst vaccination willingness did not differ among different age groups, the actual vaccination rate was significantly higher in people aged ≥ 40 years, which is consistent with the findings in other countries. 23, [36] [37] [38] [39] This presumably because . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 17, 2021. ;  the immune function decreases with age and the incidence and mortality of COVID-19 are relatively higher in older adults. 40 Furthermore, young people often do not have a strong demand for vaccines and tend to adopt a wait-and-see attitude. This attitude was likely heightened because the pandemic was effectively controlled in China. Hence, the vaccination behavior of younger individuals was observed to be less than the elderly. A survey conducted among young people and medical students also found a lack of preventive attitudes when facing the COVID-19 epidemic. 41 We observed that HCWs from fever clinics were more likely to be vaccinated, whilst most HCWs believed that high-risk groups should have priority. Moreover, Nguyen et al. found that the acceptance of the seasonal influenza vaccine was related to the fear of getting infected (66%). 46 Given these, the mortality and infectivity of the virus might be influencing factors for vaccine acceptance. The participants in this study are HCWs who have better knowledge of the SARS-CoV-2 virus compared to the general public, and, consequently, the vaccination rate and intentions were higher. This shows the importance of raising public's awareness of the SARS-CoV-2 virus when promoting the vaccination throughout the country. The authorities may also need to start educational campaigns much earlier in future public health emergencies.

As reported by the previous research, the most common reason for vaccination resistance was concern about its side effects. 23, 29, 47 One study showed that the adverse reactions of the SARS-CoV-2 vaccine are similar to those of the influenza vaccine after vaccination 48 and the . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 17, 2021 normal and systemic reaction rates for the influenza vaccine are 2.7% and 3.0%, respectively. 49 This may help to explain why subjects in this study who reported self or family history of influenza vaccination were more likely to be vaccinated, since they are more familiar with the potential side effects of the SARS-CoV-2 vaccine. Furthermore, Nguyen et al. showed that non-physicians may be more concerned about the vaccine's safety than physicians, 46 suggesting that the general public may be more worried about the vaccine due to their lack of knowledge. Therefore, healthcare agencies need to increase vaccine-related education to the general public, particularly on: (1) the development and manufacturing processes for vaccines;

(2) the similarities between the seasonal influenza vaccine and the SARS-CoV-2 vaccine; and

(3) the efficiency and safety of vaccines based on the latest clinical trials. Moreover, authorities should strive to publish the true reason for side effects, which could help to distinguish legitimate safety concerns from events that are temporally associated with but not caused by vaccination. The inappropriate assessment of vaccine safety data can severely undermine the acceptance of the vaccine, and, consequently, influence the success of a mass vaccine campaign. 50, 51 This study has certain limitations. Firstly, at the completion of this survey, China has not recommended the vaccination for people over 60 years old. The vaccination status and associated factors among HCWs in this age group could not be analyzed. However, as most HCWs in China retire when they reach 60, the population in this study is likely to represent HCWs who were working at hospitals during the time of data collection. Secondly, we only conducted a cross-sectional multivariate analysis of the survey data, which can only show the correlation between each factor and vaccination willingness and vaccination behavior, but it cannot prove its causality; therefore, further longitudinal studies are necessary. Finally, as this study was based on self-reported data, it has certain weaknesses that may serve as sources of bias in data interpretation. Despite these limitations, the large sample size of this study and the representative demographics of Chinese HCWs provides relevant information on the vaccination status of HCWs and a reference for the subsequent formulation of vaccination policies.

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The copyright holder for this preprint this version posted May 17, 2021. ; https://doi.org/10.1101/2021.05.15.21257094 doi: medRxiv preprint

Protecting HCWs against COVID-19 is crucial for maintaining the efficacy of the healthcare system during the pandemic. This study suggests that the characteristics of HCWs, working environment, and familiarity and confidence of the vaccine were related to the self-reported willingness to receive the vaccine. Results of this study can not only help to formulate pertinent policies and increase vaccination coverage, they may also provide instructions for future public health emergencies. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 17, 2021. ; https://doi.org/10.1101/2021.05.15.21257094 doi: medRxiv preprint

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Xinxin Ye and Peige Song designed the study. Xinxin Ye, Wan Ye, Yuzhen Gao managed and analysed the data. Xinxin Ye, Wan Ye, Jinyue Yu and Ziyang Ren prepared the first draft. All authors were involved in revising the paper and gave final approval of the submitted versions.No funding received for this study.

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