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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 86-95

Awareness, perception, and acceptance of coronavirus vaccines by health-care workers approved for restricted emergency use in India: A web-based cross-sectional study


1 Regional Research Institute, Imphal, Manipur, India
2 Interventional Pulmonologist and Independent Researcher, Lucknow, Uttar Pradesh, India

Date of Submission01-Jul-2021
Date of Acceptance15-Jan-2022
Date of Web Publication21-Jun-2022

Correspondence Address:
Dr. Ravi Bhaskar
Sector 20, House No 25, Indira Nagar, Lucknow - 226 016, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijam.ijam_85_21

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  Abstract 


Introduction: Health-care workers (HCWs) have been designated as the highest priority group to receive the coronavirus (CoV) vaccine. The study aimed to assess the awareness and perception about the CoV vaccine and the factors associated with the acceptance or rejection of vaccines among HCWs in India.
Materials and Methods: An online cross-sectional study using a convenience sampling method was conducted between January 5 and January 14, 2021, just before the initiation of CoV vaccination among HCWs in India. Questions to assess awareness and perception were developed based on the information available on the public health websites. HCWs' willingness to accept the vaccines was also studied along with the factors associated with acceptance or rejection of CoV vaccination.
Results: The study received responses from 496 HCWs. Awareness about the CoV vaccine was low, with a mean score of 5.44 (standard deviation = 2.91). Willingness to accept CoV vaccination was found in 63.51% of HCWs with the main reason to protect their family and colleagues (43.73%). The majority of HCWs agreed with the emergency authorization of CoV vaccines (65.93%) and agreed that vaccines will break the chain of transmission of infection (65.73%). Perception of vaccine effectiveness (odds ratio [OR] = 8.52, P = 0.000) and higher awareness (OR = 2.86, P = 0.000) were significantly associated with willingness to accept CoV vaccination.
Conclusion: HCWs have the responsibility to disseminate correct information and risks about vaccinations among the public. Health authorities should continue encouraging the increase of the knowledge and awareness of the utility of vaccines among HCWs.
The following core competencies are addressed in this article: Medical knowledge, Professionalism, Patient care and procedural skills, and Systems-based practice.

Keywords: Coronavirus disease 2019, mass vaccination, pandemics, vaccination coverage, vaccination refusal, vaccines


How to cite this article:
Srivastava A, Bala R, Bhaskar R. Awareness, perception, and acceptance of coronavirus vaccines by health-care workers approved for restricted emergency use in India: A web-based cross-sectional study. Int J Acad Med 2022;8:86-95

How to cite this URL:
Srivastava A, Bala R, Bhaskar R. Awareness, perception, and acceptance of coronavirus vaccines by health-care workers approved for restricted emergency use in India: A web-based cross-sectional study. Int J Acad Med [serial online] 2022 [cited 2022 Jul 2];8:86-95. Available from: https://www.ijam-web.org/text.asp?2022/8/2/86/347826




  Introduction Top


Coronavirus disease 2019 (COVID-19) is an infectious disease caused by a newly discovered coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]), which has spread rapidly throughout the world. In March 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic.[1] India has reported a large number of confirmed COVID-19 cases and deaths like many other countries.[2] While countries, including India, have taken strong measures to contain the spread of COVID-19, vaccines will provide a lasting solution by enhancing immunity.[1]

Respiratory viral infections are highly contagious infecting 5%–15% population worldwide annually.[3] Health-care workers (HCWs) are believed to be at increased risk of respiratory viral infections because of the close contact with the patients. Vaccination of HCWs against respiratory viral infections is an important component of infection control in health-care settings, but a persistently low rate of vaccine uptake among HCWs in most countries remains an international concern.[4] Numerous studies on vaccine acceptance and rejection have been conducted among HCWs,[5],[6] however, much less is known about the barriers to vaccine acceptance.[4] Specifically, lack of knowledge on the risk related to the infections and concern regarding the vaccine have frequently emerged as determinants of vaccine hesitancy among HCWs.[7]

In few countries, the presumption of protection through a so-called herd immunity failed and most countries enforced temporary lockdown to control the spread of infection.[8] The Central Drugs Standards Control Organization on January 2, 2021, granted permission to the Serum Institute of India Covishield for restricted use in an emergency situation and Bharat Biotech's Covaxin for restricted use in an emergency situation in clinical trial mode.[9] A strong immune response is required to remove the SARS-CoV-2 infection from the human body which is manifested by a strong T-cell response to the virus, which may help them recover from the virus.[10]

The Government of India (GOI) initiated the world's largest vaccination program for COVID-19 on January 16, 2021, with a target of vaccinating 30 million HCWs and frontline workers in the first phase of the vaccination drive. Studies around the world have reflected the vaccine hesitancy, however, not much is known about the barriers to vaccine acceptance among HCWs in India. This study aimed to assess the awareness level about CoV vaccines and to study the factors associated with acceptance or rejection of CoV vaccines authorized for restricted use in emergency situations among HCWs in India.


  Methodology Top


Study setting

An online cross-sectional study was conducted from January 5 to January 14, 2021, just before the start of CoV vaccination to HCWs in India. HCWs aged 18 years or above were included in the study.

Study procedure

A convenient sampling method was chosen and a web-based collection of data using Google Forms was adopted that was circulated widely through text message and social media platforms such as Facebook and WhatsApp. The development and reporting of the survey followed the Checklist for Reporting Results of Internet E-Surveys guidelines (CHERRIES).[11]

Study instruments

The self-reported questionnaire was developed as per the information available on websites of the Ministry of Health and Family Welfare, GOI,[12] WHO,[13] and Centers for Disease Control and Prevention, United States of America.[14] The draft questionnaire was sent to five experts, and the final version was prepared after the consensus of the experts. A pilot testing was conducted for face and content validity for all items and also for feasibility, ease of understanding, and time taken to fill the questionnaire.

The questionnaire was in English language, and the Google Forms created for the study had five sections. The first section informed the participants about the background, objectives of the study, and confidentiality of identity. HCWs who consented to willingly participate in the study were directed to the second section that consisted of questions on sociodemographic characteristics. The third section had 12 questions to assess the level of awareness of HCWs regarding CoV vaccines. A correct response was assigned 1 point while a wrong response was assigned 0 point, and they were added to get a total awareness score that ranged from 0 to 12, with higher scores indicating awareness of CoV vaccines. Section 4 had six questions on willingness to accept CoV vaccination, the reasons for such willingness or unwillingness, and concerns regarding the vaccines. Section 5 consisted of seven questions that recorded the response of HCWs on their perception toward CoV vaccines and their emergency authorization with five questions having response options of “agree,” “disagree,” and “not sure.” The complete questionnaire is given in [Supplementary Table 1[Additional file 1]].

Statistical analysis

Fully completed questionnaires were extracted from Google Forms and exported to a spreadsheet for cleaning and coding which was analyzed using Microsoft Excel software (Microsoft, Redmond, WA, USA). The frequency and percentage of correct awareness response and perception were described. The descriptive analysis gave mean scores and standard deviation (SD) of responses under the awareness section. The independent sample t-test, analysis of variance, and Chi-square test were used as appropriate for finding a significant difference in awareness scores, perception, and acceptance of CoV vaccines based on demographic variables. Binary logistic regression analysis was performed to identify factors significantly associated with the acceptance of CoV vaccines. Odds ratio (OR) and their 95% confidence interval (CI) were used to quantify the associations between factors and CoV vaccine acceptance. The post hoc test revealed groups that differed significantly on awareness scores. The statistical significance level was set at P < 0.05.

Ethics statement

The study was approved by the Institutional Ethical Committee of the first author's institute (Reference Number: 2-28/825). The study was conducted in accordance with the Declaration of Helsinki. The authors adhered to the appropriate EQUATOR recommendations (http://www.equator-network.org/), and specific CHERRIES[11] guidelines have been followed. The study methodology has been outlined with sufficient detail to allow reproducibility of study design.


  Results Top


The study received 502 responses, and after removing the incomplete entries, the final dataset consisted of 496 responses. The mean age (SD) of the participants was 33.86 (10.90) years. There was equal participation of doctors with graduate and postgraduate qualifications (n = 134, 27.02%) while a majority of participants were with graduate qualifications (n = 230, 46.37%). Few HCWs had been infected with CoV (n = 43, 8.67%) while a family member of 129 (26.01%) HCWs had been already infected with CoV [Supplementary Table 2[Additional file 2]]. The response to questions on awareness about CoV vaccines is given in [Supplementary Table 3[Additional file 3]]. The awareness about CoV vaccines as shown in [Table 1] was significantly higher among HCWs who were married (P = 0.000), suffering from non-communicable diseases (NCDs) (P = 0.000), and whose family members had tested COVID-19 positive (P = 0.000). Significant difference in awareness level was found among demographic groups according to age (P = 0.000), type of area (P = 0.002), education (P = 0.000), occupation (P = 0.000), source of information (P = 0.000), and those who practiced alternative for vaccination (P = 0.023). The post hoc analysis [Table 2] indicated that subjects in age group above 41 years (vs. 18–30 years, Q = 9.563, P = 0.001 and vs. 31–40 years, Q = 4.727, P = 0.003), age group 31–40 years (vs. 18–30 years, Q = 4.972, P = 0.001), living in urban areas (vs. rural areas, Q = 4.673, P = 0.003) as well as semi-urban areas (vs. rural areas, Q = 3.783, P = 0.021), qualification of postgraduate and above (vs. intermediate or diploma, Q = 5.715, P = 0.001 and vs. graduate, Q = 5.124, P = 0.001), and occupation of doctors with a postgraduate qualification (vs. doctors with graduate, Q = 7.374, P = 0.001; vs. pharmacist, Q = 9.839, P = 0.001; and vs. others Q = 10.337, P = 0.001) showed a significantly higher awareness about CoV vaccine.
Table 1: Assessment of awareness on coronavirus vaccine based on demographic variables

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Table 2: Post hoc test on awareness concerning coronavirus vaccines

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HCWs were willing to get vaccinated for CoV (n = 315, 63.51%), to advise their loved ones, friends, and family members to get vaccinated (n = 361, 72.78%), and to advise the patients to get vaccinated (n = 374, 75.40%). The perception of HCWs toward CoV vaccines is given in [Supplementary Table 4[Additional file 4]]. The main reason for accepting the CoV vaccine by HCWs [Figure 1] was to protect their family and colleagues (43.73%) and to lower the risk of transmission to the patients (23.15%). HCWs who were not willing to accept the CoV vaccine stated that they followed preventive guidelines (26.01%) and were young and healthy (23.70%) and thus do not require vaccination [Figure 2]. Safety profile (41.33%) and vaccine efficacy/effectiveness (21.37%) were the main concerns among HCWs regarding CoV vaccines [Figure 3].
Figure 1: Main reasons for accepting coronavirus vaccine (N = 311)

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Figure 2: Main reasons for not accepting coronavirus vaccine (N = 173)

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Figure 3: Main concerns regarding coronavirus vaccines (N = 496)

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The Chi-square analysis [Table 3] showed that married HCWs were more willing to get vaccinated (P = 0.009) and to advise vaccination to the family (P = 0.006) and patients (P = 0.004). Similarly, participants who were suffering from any NCD were more willing to get vaccinated (P = 0.002). The demographic group of age showed a significant difference in willingness to get vaccinated for CoV (P = 0.005) and in advising the same for patients (P = 0.042), while the group occupation showed a significant difference in advising their family and friends to get vaccinated (P = 0.014). HCWs who practiced alternative of vaccination showed a significant difference in acceptance of vaccination for all three questions (P = 0.000). Logistic regression analysis [Table 4] found that HCWs who perceived severity of COVID-19 as fatal (vs. mild, OR = 2.82, P = 0.004), who agreed that vaccine would be effective in preventing CoV infection (vs. disagree, OR = 8.58, P = 0.000 and vs. not sure, OR = 4.93, P = 0.000) and with higher awareness score (OR = 2.86, P = 0.000) were significantly associated with willingness to accept CoV vaccination. Similarly, HCWs with higher awareness score (OR = 1.89, P = 0.013), who agreed with emergency authorization of CoV vaccine in India (vs. not sure, OR = 1.63, P = 0.043), and who agreed that vaccine would be effective in preventing CoV infection (vs. disagree, OR = 11.87, P = 0.000 and vs. not sure, OR = 5.33, P = 0.000) were significantly willing to advise CoV vaccination to their family and friends. Furthermore, HCWs with higher awareness score (OR = 1.83, P = 0.024) and who agreed that vaccine would be effective in preventing CoV infection (vs. disagree, OR = 9.99, P = 0.000 and vs. not sure, OR = 5.52, P = 0.000) were significantly willing to advise CoV vaccination to the patients.
Table 3: Chi-square test showing association between vaccine acceptance and demographic variables

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Table 4: Result of logistic regression analysis on factors significantly associated with acceptance of coronavirus vaccine

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There was a significant difference in perception of HCWs [Table 5] toward authorization given for emergency use of CoV vaccine in India among demographic groups of occupation (P < 0.01) and who practiced alternative for vaccination (P < 0.05). The perception of HCWs that CoV vaccines were not tested adequately differed significantly across gender (P < 0.05), education, occupation, source of information (P < 0.01 for each), age, and who suffered from NCD (P < 0.001 for both). The demographic groups of age, marital status, occupation (P < 0.001 for each), education, who tested positive, suffered from NCD (P < 0.05 for each), and source of information (P < 0.01) significantly differed in perception that there was lack of transparency regarding the CoV vaccines.
Table 5: Chi-square test showing association of health-care workers' perception toward coronavirus vaccine and demographic variable

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  Discussion Top


To the best of our knowledge, this is one of the earliest studies among HCWs from India that examined the factors associated with awareness, perception, and acceptance or hesitancy toward CoV vaccination. HCWs consistently discharge their duties at the frontline and are at high risk of contracting the infection. HCWs remain the most trusted and credible source of information for patients in general and specifically concerning COVID-19.[15] Higher confidence in vaccines among HCWs could positively influence the attitude and belief of the general population toward CoV vaccine acceptance.[16]

In this study, 63.51% of HCWs were willing to accept the CoV vaccine with similar findings from a study in Hong Kong.[17] Studies among the general population from America (51%),[18] Australia (81%),[19] and Saudi Arabia (65%)[20] reported varying levels of CoV vaccine acceptance. A survey (N = 20,000) conducted in 27 countries showed that 74% of adults intended to receive the COVID-19 vaccine, with the highest rates in China (97%) and the lowest in Russia (54%).[21] The difference in willingness to accept the CoV vaccine in this study compared to other studies might be due to differences in sociocultural norms and geographic distribution. India had successfully controlled the first wave of the COVID-19 pandemic, and the results of the steps taken by GOI were evident by the continuous decreasing COVID-19 cases by each passing day.[2],[12] However, India experienced a massive surge in COVID-19 cases and deaths during the second wave of the pandemic beginning March 2021 which may be attributed to the fact that not many people were vaccinated against the virus as the vaccine rollout was extended to people over 60 years of age and those with comorbidities aged 45–59 years from March 2021 onward.[2],[12] The successful management of the pandemic crisis at the time of conduction of this study may also be the cause of relatively low vaccination acceptance. Information on vaccine trials and the approval process of the vaccines for emergency use may also be the key factors in acceptance or hesitancy toward vaccines.[22]

Similar to a European study, the level of awareness among HCWs in this study about the CoV vaccine authorized for emergency use in India was not sufficiently high.[15] Conversely, significantly high awareness was observed in the age group above 41 years (P = 0.001) which was in sync with another study.[23] Health and vaccine literacy can be considered as determinants of vaccine confidence,[22] however, knowledge and awareness about a vaccine are not directly proportional to vaccine acceptance which is also reflected in this study.[24] The communication strategy employed in India by GOI seeks to disseminate timely, accurate, and transparent information about the vaccines that will alleviate apprehensions and will ensure its acceptance and encourage uptake.[12]

HCWs willing to get vaccinated for COVID-19 in this study want protection both for themselves and for their family and colleagues as they consider CoV vaccines to be effective. HCWs who showed hesitancy felt that they are healthy and followed preventive practices against COVID-19 and such attitudes were previously reported in few surveys.[25],[26] Confidence in acceptance of CoV vaccines among HCWs is also found related to the use of alternative therapies to vaccination as also observed in another study.[23] Safety profile (41.33%) and vaccine efficacy/effectiveness (21.37%) were the main concerns among HCWs regarding CoV vaccines, and similar concerns were expressed in other studies also.[25],[27] Mistrust in the vaccine safety, protective effects, and concerns about their adverse effects are the biggest roadblocks toward acceptance of the vaccine.[28] As CoV vaccines are still undergoing trials, not much data is available on long-term adverse effects.[29] Hence, it is imperative that an effective mechanism should be put in place to monitor the adverse effects in HCWs and later in the general population. People have to be taken into confidence that unknown and severe adverse events are likely to be very uncommon. It is postulated that the likelihood of an individual adopting a specific health behavior is determined by the belief in a personal threat of illness and the effectiveness of the recommended health behavior.[30]

The perception among HCWs was that the vaccine will be effective in breaking the chain of transmission (65.73%), though they were concerned that the vaccine has not been tested adequately (39.92%) and that there is a lack of transparency regarding the CoV vaccines (43.95%). The expedited development of the vaccine may create an impression in the public that the vaccine might not have been tested adequately for safety and efficacy.[18] The hesitancy due to fast-tracked clinical trials and approval may reduce the willingness to get the vaccine.[18] HCWs who perceived COVID-19 to be fatal and whose likelihood of acquiring CoV infection was perceived to be higher were significantly more willing to accept CoV vaccination, with similar findings being reported in another study.[18] The results regarding vaccine information sources are similar with past researches showing preference toward the internet.[23],[31]

There has been a decline seen in the percentage of actual vaccination uptake among HCWs regardless of the high intentions to get vaccinated.[31] Global equitable access to a vaccine, particularly protecting HCWs and those more at risk, is the only way to mitigate the public health and economic impact of the pandemic and is the current priority.[1] This study has some limitations. First, a convenience sampling method deployed may have caused a selection bias that may limit the generalizability of the result, but the study recruited HCWs from 25 states and union territories of India and thus is representative of the HCW population. Second, cross-sectional analysis assessed the vaccine acceptance/hesitancy just before the launch of the COVID-19 vaccination program in India and did not follow the respondents to capture their actual practice and acceptance. Third, the Likert scale used may have had a bias toward an agreement, as there was no midpoint (neutral). Fourth, the study was conducted at a time when the COVID-19 pandemic was showing signs of easing out that might have influenced the willingness to accept the expedited vaccine. Despite these limitations, this is one of the earliest studies conducted in India that was able to assess the predictors of COVID-19 vaccine uptake intention.


  Conclusion Top


The result of the study suggests that there are significant levels of CoV vaccine distrust that must be addressed to ensure maximum uptake of any COVID-19 vaccine. Trust and confidence in the CoV vaccine, its efficacy, and its ability to break the chain of transmission of infection will be crucial to generate confidence in HCWs in the vaccines. HCWs have the additional responsibility to disseminate correct information and risks about CoV vaccinations among the public. Strategies to improve the knowledge, confidence, and communication skills of HCWs need to be implemented to ensure that the eligible groups receive that vaccine with confidence. The hesitancy of HCWs and the public should be addressed on the COVID-19 vaccination process by providing correct, consistent, and timely information on the availability, safety, and timelines of new COVID-19 vaccines and vaccination processes. Equally essential is to address the low-risk perception of the infection amongst people and build an enabling environment to adopt and maintain COVID appropriate behaviors to reduce any risks of infection.

Acknowledgment

The authors like to thank all the HCWs who participated in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical conduct of research

The study was approved by the Institutional Ethical Committee of the first author's institute (Reference Number: 2-28/825). The study was conducted in accordance with the Declaration of Helsinki. The authors adhered to the appropriate EQUATOR recommendations (http://www.equator-network.org/), and specific CHERRIES[11] guidelines have been followed. The study methodology has been outlined with sufficient detail to allow reproducibility of study design.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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