key: cord-0873744-wzgznmij authors: Ibrahim Arif, Samir; Mohammed Aldukhail, Ahmed; Dhaifallah Albaqami, Meshari; Cabauatan Silvano, Rodella; Titi MSN, Maher A.; Arif, Bandar I.; Amer, Yasser S.; Wahabi, Hayfaa title: Predictors of Healthcare Workers' intention to vaccinate against COVID-19: A Cross Sectional Study from Saudi Arabia date: 2021-12-05 journal: Saudi J Biol Sci DOI: 10.1016/j.sjbs.2021.11.058 sha: 018ace374f88217ddc01feb75fe99f549c56dc56 doc_id: 873744 cord_uid: wzgznmij BACKGROUND: Vaccination is considered the best way to prevent the spread of COVID-19 and to prevent the complications of the disease. Nevertheless, no awareness campaigns were conducted in Saudi Arabia until March 1, 2021, when the Vaxzevria, or ChAdOx1 nCoV-19 (AZD1222), vaccine became available. OBJECTIVES: This study aims to determine the factors that can predict healthcare workers’ acceptance of the COVID-19 vaccine. METHODS: A cross-sectional study was conducted from July to September 2021, in our university tertiary hospital (King Saud University Medical City [KSUMC]), Riyadh, Saudi Arabia. The study targeted potential participants among healthcare workers at KSUMC. We assessed healthcare workers’ perceptions and beliefs about the COVID-19 vaccine via a questionnaire that was distributed via social media applications such as WhatsApp, Twitter, and Google. Participants were informed about the questionnaire before they filled it out, and they were asked to respond to three screening questions before beginning the main questionnaire. These screening questions ensured that the participants met the inclusion criteria. Included participants were over the age of 18, agreed to answer the questions, and were residents of Saudi Arabia. The participants filled out the self-administered questionnaire. RESULTS: A total of 529 participants completed the questionnaires. All participants were vaccinated, 68% were female, 55% were married, 35% had been working for less than five years, and 65% had a bachelor’s degree. More than half of participants had not previously been infected with COVID-19, and most did not interact with COVID-19 patients. More convenient access to the vaccine increased the odds ratio of participant vaccination by 0.39. An increase in the number of vaccinated friends and family members increased the odds ratio of participant vaccination by 0.30. However, COVID- 19 vaccination mandates decreased the odds ratio of participant vaccination by 0.27. The fitted linear regression model explained 32% of the variation observed in the dependent variable, acceptance of the COVID-19 vaccine, and the adjusted R squared was 0.32. The fitted regression model was statistically significant at a 95% confidence interval; the p-value was 0.00001. CONCLUSION: In Saudi Arabia, there is an immense need to increase uptake of the COVID-19 vaccine. This requires encouraging more positive beliefs and attitudes regarding vaccination in general and the COVID-19 vaccine in particular. Results: A total of 529 participants completed the questionnaires. All participants were vaccinated, 68% were female, 55% were married, 35% had been working for less than five years, and 65% had a bachelor's degree. More than half of participants had not previously been infected with COVID-19, and most did not Coronavirus disease 2019 (COVID-19) is highly contagious and is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Lai et al., 2020) . On January 30, 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a public health emergency of international concern (Jee, 2020) . During the first six months after the initial outbreak, more than ten million COVID-19 cases were confirmed worldwide; 20,000 of these were in Saudi Arabia (Awwad et al., 2021) . Although several vaccines are now available and approved in many countries and although none of the underdevelopment COVID-19 vaccines have reached the market, vaccination is considered the most effective strategy for ending the pandemic and avoiding the complications associated with the disease (Thanh et al., 2020; Schaffer et al., 2020) . However, Larson et al. (2016) and Bankamp et al. (2019) have shown that the decision to take available vaccines is dependent on beliefs and perceptions. Therefore, worldwide concern about public acceptance of the COVID-19 vaccines has been increasing Khan et al., 2020) . A recently published review indicates varying levels of vaccine acceptance and hesitancy globally (Xiao and Wong, 2020) . Most surveys of COVID-19 vaccination acceptance report low rates of acceptance in the Middle East, Russia, Africa, and several European countries (Almotairy et al., 2019; Alqahtani et al., 2017) . Further studies are needed to address COVID-19 vaccine hesitancy, especially in the Middle East, North Africa, Sub-Saharan Africa, Eastern Europe, Central Asia, and Middle and South America. Addressing COVID-19 vaccine hesitancy is the first step of building trust in COVID-19 vaccination efforts (Sallam, 2021) . In Saudi Arabia, a COVID-19 vaccine is expected to face significant public hesitancy given the current public hesitancy toward seasonal influenza vaccination (Almotairy et al., 2019; Alqahtani et al., 2017) . Although few studies have explored hesitancy toward COVID-19 vaccination, existing studies have found that acceptance and hesitancy rates towards any vaccine vary around the world (Xiao and Wong, 2020). National health authorities have made significant efforts to improve awareness of the COVID-19 vaccines and their importance. In Saudi Arabia, COVID-19 vaccines have been made available in three priority stages; the first stage includes elderly people and all healthcare providers. Local awareness campaigns at our institution started after the arrival of the first batch of COVID-19 vaccines. Our study aimed to assess healthcare workers' beliefs about and barriers to COVID-19 vaccination. This study was conducted because misinformation disseminated via numerous sources may have a significant impact on COVID-19 vaccination uptake. The faster-than-usual speed of vaccine development has heightened public concern and may jeopardize vaccine uptake. Therefore, governments and communities must assess current levels of willingness to receive a potentially safe and effective COVID-19 vaccine and identify predictors of vaccination hesitation and/or adoption (Cornwall, 2020; Fadda et al., 2020) . Therefore, the present study aims to identify factors that can predict healthcare workers' acceptance of the COVID-19 vaccine. The study is a cross-sectional, hospital-based online survey that was conducted therefore, copyright was not an issue. All participants were briefly informed about the objectives of the study and about the procedure; they could then opt to complete the questionnaire or not. Non-probability, a non-random sampling technique in the form of a convenient purposive sample, was used to select participants. For this qualitative study, participants were selected via purposive sampling. With this method, it is not necessary to obtain a statistically representative sample; any number of participants (i.e., any sample size) can be used. The sample size is therefore determined by the facts, data, and available resources. The confidence level and margin of error are calculated based on the number of participants and complete responses received. Administrative and non-administrative healthcare workers at KSUMC were invited to participate in the survey. Participants aged 18 years and older who reside in Saudi Arabia were included in this study. Participants who were unwilling to participate in the study were excluded. The study data were collected using a secure web-based platform, Google Forms. The one-time web survey link was sent to employees via e-mail or WhatsApp. Participants who read the introductory information and subsequently completed the questionnaire were considered to have provided informed consent to participate in the study. Before they saw the main questionnaire, participants were asked three screening questions to ensure that they met the inclusion criteria (i.e., at least 18 years of age, resident of Saudi Arabia, and willing to share their responses). Eligible hospital staff at occupational health and safety clinic (OHSC) and KSUMC employees and staff members who were willing to participate completed the study voluntarily. Individuals not employed at KSUMC and those who were unwilling to participate were excluded from the study. The questionnaire was developed specifically for this study based on tools used in previous studies and discussions within the research team (Paul et al., 2021; El-Elimat et al., 2021) . The final questionnaire was structured into three sections. The first section collected sociodemographic data, and the second section explored participants' beliefs and attitudes toward vaccination against COVID-19. The third section was designed to identify barriers to vaccination against COVID-19. The questionnaire was provided in English and Arabic. The Arabic version was translated into English using the backward-forward method, and the translation was double-checked by the authors (Paul et al., 2021; El-Elimat et al., 2021) . A pilot sample (n=30) was used to assess the reliability and validity of the questionnaire. We conducted statistical analysis to measure internal consistency. The study commenced after ethical approval was received from the Institutional Review Board of King Saud University (#E-21-5871). Data confidentiality and participant anonymity were protected by assigning a code number to each participant for the data analysis. Participation in the study was completely voluntary. No rewards were given to the participants. They were also informed of their right to withdraw from the study at any time without obligation. Collected data were stored in a secure server that only members of the study team could access. The identity of all participants will remain anonymous in the published research. To avoid non-response bias, we sent a pre-notification email to potential participants informing them about the upcoming survey. We also sent personalized invitations and one reminder to potential participants. To avoid response bias, the survey questions were neutrally phrased, and the answer choices were not leading. The survey was conducted anonymously. We also reduced order bias by reducing the number of questions to the bare minimum and grouping survey questions by topic. Demographic questions were asked later in the survey. We also sought to ask question that would engage respondents and randomized our question and answer options. responses rated three indicated the most positive attitude. The total score was calculated by averaging the values of the total responses. A score greater than two indicates a positive attitude, while a score less than two indicates a negative attitude. A chi-squared test was used to measure the impact of sociodemographic variables on COVID-19 vaccination acceptance. The odds ratio was calculated using logistic regression analysis. Variables that predict vaccine acceptance were calculated using 95% confidence intervals. A p-value greater than .05 is considered statistically significant. The demographic statistics are shown in Table 1 However, the infection rate was almost the same for those who worked with COVID-19 patients and those who did not. This indicates that healthcare workers exposed to COVID-19 patients did not have a greater risk of infection than their counterparts who did not work with COVID-19 patients. As Table 1 shows, 52.78% of the participants know someone (a relative or friend) who has been infected with COVID-19 or who has died from COVID-19. The rest, 46.58% of the sample, had no previously infected relatives or friends. 52.86% is more than half of the participants. Table 2 shows the chi-squared analyses, which were used to determine the relationship between COVID-19 vaccine acceptance and social demographic characteristics. The results of the chi-squared analysis indicate a significant relationship between gender and COVID-19 vaccine acceptance. As the bar graphs show, female participants were more likely to accept the COVID-19 vaccine. Hence, the vaccine acceptance ratio was higher in female participants than in male participants. Furthermore, participants with an income between 5,000 and 10,000 SR were more likely to accept the vaccine than those who earned less than 5,000 SR. Notably, participants earning between 10,001 and 15,000 SR were also skeptical of the vaccine. Pearson's chi-squared (P=0.0271) and the likelihood ratio (P=0.0144) are shown in Table 2 . We also found that participants who were married but separated had higher vaccine acceptance and that married participants had higher vaccine acceptance than single ones. The fitted logistic regression model explained 16% of the variation observed in the dependent variable, vaccine acceptance. Nagelkerke's R squared was 0.16 and the -2 log likelihood was 309.022a, supporting our conclusion. Only three predictor variables were statistically significant. Logistic regression was used to measure the impact of the three significant predictors of vaccine acceptance: vaccine convenience, number of vaccinated friends and family members, and vaccine mandates. As Table 3 vaccine. However, reluctance to receive an influenza vaccination has previously been observed among Irish and Saudi healthcare personnel (Halpin and Reid, 2019; Alsuhaibani, 2020) . In a randomized clinical study, Dempsey et al. (2018) highlight the beneficial impact of healthcare professionals on teenagers' uptake of the human papillomavirus vaccination. Our findings also indicate that the preventive measures to protect frontline healthcare workers in Saudi Arabia from contracting COVID-19 are effective. Therefore, healthcare workers who interact with COVID-19 patients should not face discrimination. COVID-19 has spread, and most participants in the present study have firsthand knowledge of the virus rather than only information from the media. Therefore, the Saudi government should continue to implement measures aimed at reducing the spread of the disease. Other studies have identified several variables related to COVID-19 vaccine acceptance. We found that males were more likely than females to accept COVID-19 vaccination, which supports previous results (Wong et al., 2020; Malik et al., 2020) . We also found that vaccine acceptance was highest among high-income individuals and lowest among low-income participants. These results align with those of another study in the United States; there, vaccine acceptance was also higher among high-income participants than among those with lower incomes (Reiter et al., 2020) . Other studies have also found a relationship between vaccine acceptance and marital status. These results may be explained by views and opinions regarding immunization, which vary across age groups. However, married participants should seek to increase COVID-19 vaccination acceptance among individuals who are more susceptible to COVID-19-related problems (Malik et al., 2020; Bonanad et al., 2020; Lazarus et al., 2020) . We also found that COVID-19 vaccine acceptance varied by level of education; highly educated participants were more likely to accept the vaccine than those with lower levels of education, and doctors were more eager to be vaccinated than those in other healthcare professions. Public health initiatives should address these differences in vaccination acceptance based on demographic and socioeconomic factors in order to reduce inequalities and increase vaccine acceptance (Dror et al., 2020). Interestingly, before the H1N1 influenza A pandemic, the public vaccination acceptance rate in the United States was 8.7% (Quinn et al., 2009) . However, when a vaccine for H1N1 was brought to the market, self-reported vaccination uptake rose to 20% (Maurer et al., 2010) . Given that vaccination is the cornerstone of reducing the healthcare burden of the COVID-19 pandemic, this study's findings may be used to design evidence-based immunization programs while a vaccine is being developed (Fadda et al., 2020) . Enhancing public attitudes toward vaccination and identifying the obstacles to COVID-19 vaccination acceptance can increase vaccine acceptance, which may result in increased vaccine uptake when it becomes accessible. The present study has several limitations. Due to the curfew and social distance limitations imposed due to COVID-19, data were collected through an online self-administered questionnaire rather than in face-to-face interviews. In addition, only healthcare professionals were included in our sample. Therefore, underrepresentation and reporting bias could be issues. Furthermore, this cross- The present study found that COVID-19 vaccine hesitancy among Saudi healthcare workers was twice that reported in China, the United States, or Egypt Thunstr'm et al., 2020; Abdelhafiz et al., 2020) . 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