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Community health workers willingness to participate in COVID-19 vaccine trials and intention to vaccinate: A cross-sectional survey in India

Open AccessPublished:July 30, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101113

      Abstract

      Background

      Vaccine hesitancy is of considerable concern as it threatens the great potential of a vaccine against COVID-19. This study aims to determine factors associated with community health workers’ willingness to participate in clinical trials of COVID-19 vaccine, and their vaccination intention, in India.

      Methods

      A cross-sectional study was conducted among 377 community health workers using self-administered anonymous questionnaire during the lockdown periods in India. Participant's socio-demographics, willingness-to-participate in COVID-19 vaccine trials, intention to accept COVID-19 vaccine were recorded in a Likert scale. Data were analysed descriptively, and a multivariate logistic regression model was used to investigate factors associated with willingness to participate and accept the vaccine.

      Results

      Among 377 CHWs, 70 (19%) intended to participate in COVID-19 vaccine trial, 151 (40%) responded positively regarding their intention to get vaccinated. Those with knowledge on development of COVID-19 vaccine [aOR 3.05 (95% CI: 1.18–7.88), p = 0.021], and men [aOR 3.69 (95% CI: 1.51–8.97), p = 0.004] were more willing to participate in clinical-trial, while an undergraduate degree, and trust in domestic vaccines were identified as deterrents for the same. Perceiving COVID-19 as risk [aOR 2.31 (95% CI: 1.24–4.31), p = 0.009], and male gender [aOR 2.39 (95% CI: 1.17–4.88), p = 0.017] were factors associated with intention to get vaccinated. Respondents who had knowledge about COVID-19 virus were less likely to uptake the hypothetical vaccine [aOR 0.32 (95% CI: 0.12–0.88), p = 0.027].

      Conclusions

      Increasing knowledge regarding COVID-19 is not enough to improve vaccine acceptance rates. Targeted interventions addressing socio-demographic determinants related to COVID-19 vaccination should help improve acceptance.

      Keywords

      Abbreviations:

      CHW (Community health worker), COVID-19 (Coronavirus disease-2019), WHO (World Health organization)

      1. Background

      The ongoing Coronavirus disease-2019 (COVID-19) pandemic has affected over 173 million people and caused more than 3.7 million deaths globally.
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      WHO coronavirus (COVID-19) dashboard.
      Imposing enormous morbidity and mortality burdens, the disease continues to disrupt societies and economies across the globe. Around ten million people have been affected in India alone.
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      Working on the frontline, thousands of healthcare workers (HCW) have been infected and lost their lives in the pandemic.
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      Healthcare worker infections and deaths due to COVID-19: a survey from 37 nations and a call for WHO to post national data on their website.
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      Though exact numbers are not known, the Indian Medical Association (IMA) reported 665 physicians in India lost lives in the line of duty.
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      Over the past century, vaccines have become indispensable in eliminating and eradicating viral illnesses.
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      Government of India's focus on COVID-19 immunization is palpable as the finance minister allocated a massive ₹35,000 crores exclusively for the vaccines to bring an end to the pandemic.
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      Following the much-awaited COVID-19 vaccine launch, an estimated one crore frontline health workers, including physicians, nurses, and community health workers, have been identified for receiving the vaccine in the first phase. Genetics, race, and environment can affect vaccine response.
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      It is therefore imperative that vaccines are investigated amongst specific populations before rolling them out. High risk of acquiring infection makes frontline workers a suitable population for COVID-19 vaccine trials globally, and in India.
      Vaccine hesitancy is defined as “delay in acceptance or refusal of vaccination despite the availability of vaccination services.“
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      It is of considerable concern as it threatens the great potential of a vaccine against COVID-19. The WHO has identified “vaccine hesitancy” as one of the top ten threats to public health in 2019, globally.
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      Hesitancy and misinformation prevent the achievement of required vaccination coverage in India and in other countries. The situation is even worse following the introduction of a new vaccine.
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      A systematic review reported the acceptance rate for H1N1 influenza pandemic vaccine varied between 8% and 67%.
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      Community health worker (CHW) is a frontline public health worker, and is involved in planning, identifying target groups, community engagement, service delivery, tracking, and follow-up of healthcare delivery activities. They are critical in introducing a new vaccine. These grass-root level workers are vital interlocutors. The knowledge of “last mile” health service delivery, shared lived experience that fosters trust and credibility within communities, and previous experience in vaccination makes them indispensable to the COVID-19 vaccination drive.
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      Apart from affecting them, their intention to get vaccinated also affect the community's perception about the vaccine. Understanding key factors influencing uptake of the vaccine by CHWs may help policymakers to develop strategies for effective implementation. Since vaccine acceptance differs between countries, cultures, and due to the vaccine, itself, this study aims to determine the factors associated with community health care workers' intention to participate in a clinical trial of covid-19 vaccine, and their intention get vaccinated against COVID-19, in India.

      2. Methods

      2.1 Study design, setting, and sample

      A cross-sectional survey was conducted across major geographical regions in India during the first wave of the pandemic (November–December 2020), before the introduction of COVID-19 vaccines in India. A non-probability snowball sampling (N = 377) technique was used. Community healthcare workers (ASHA: accredited social health activist; MPHW: Multi-purpose health worker; and CHO: Community Health Officer) were contacted through social media (WhatsApp, Telegram, Facebook, Twitter) and were requested to share the invitation link with their peers. The sample size was calculated using OpenEpi Version 3.01 with a hypothesized 60% ± 5% prevalence of vaccine acceptance at 95% confidence level. The design effect was kept one. The minimal sample size, which came on estimation at 95% confidence level, was 370. CHWs, aged 18 and above and willing to participate in the study were recruited for data collection.

      2.2 Study procedure

      Web-based self-administered questionnaires were developed and shared with the participants through social media. The participants were requested to share the link with their peers in their circle. On clicking on the received link, the participants were auto directed to the informed consent page. Only those providing informed consent, were allowed to take the survey. The questionnaire was based on literature review of similar studies. It consisted of sections on 1) Socio-demographic details, including age, sex, religion, residence, income, socio-economic status, marital status, educational status, and social caste 2) Questions to understand knowledge, perception of risk of getting infected with COVID-19, trust in the health system, and willingness to accept the COVID-19 vaccine, once available. Intention to get vaccinated was assessed by the question “Do you intend to get vaccinated against Coronavirus when the vaccine is available?” followed by the response options, “yes,” “no,” and “not sure.” Based on their response, they were asked why they intended/did not intend/were not sure to get vaccinated through pre-specified reasons followed by response options, “yes” and “no.” For assessing knowledge regarding COVID-19 and COVID-19 vaccine, participants were asked, “Before this interview, were you aware that COVID-19 virus is currently circulating in the community?“, and “is there currently a vaccine being prepared for the pandemic coronavirus strain?”. To understand the history of vaccine hesitancy, “have you ever postponed a vaccine recommend by a physician?“, “have you ever refused a vaccine for yourself or a child because you considered it as useless or dangerous?” were asked. Other important questions included, “how concerned are you that you or someone in your family will be infected with COVID-19 virus?“, “Do you have trust in the healthcare system to manage the current situation?“, “How confident are you on domestic vaccines?“.

      2.3 Data analysis

      Participant characteristics were summarized using frequency (percentage). Responses to questions on previous immunization behavior, risk perception, knowledge on COVID-19, and personal experience regarding the disease were categorized into “Yes” and “No”. Chi square test was used to examine the distribution of intention to accept COVID-19 vaccine with respondents’ socio-demographic characteristics. Logistic regression was used to identify association between independent variables and the intention to accept the vaccine. Odds ratios (OR) and their 95% confidence intervals (95% CI) were reported. A two tailed p-value <0.05 was considered to be statistically significant. All data analysis was performed using STATA 13.0.

      2.4 Ethical consideration

      The study was approved by the Institutional Research Ethics Committee of the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. Informed consent was obtained from all study participants. Steps were taken to ensure confidentiality.

      3. Results

      Among 377 community health workers who completed the survey, 255 (68%) belonged to the age group 30–49 years, and were mostly women (n = 321, 85%). A quarter of them were resident of eastern India (n = 98, 26%) and 204 (54%) were from urban areas. A majority, 254 (67%) were from medium socioeconomic status, and 195 (52%) had a family income above INR 50000. Highest education was completion of high school/diploma for 144 (38%) participants. More than half (n = 198, 53%) belonged to the other backward caste (OBC) category, and 270 (72%) were Hindus. Most of them were married (n = 270, 72%), and had a family size of five and below (n = 276, 73%) [Table 1].
      Table 1Demographic characteristics of study participants (N = 377).
      VariablesTotal (377)
      Age
       18-29122 (32.36%)
       30-49255 (67.64%)
      Gender
       Male56 (14.85%)
       Female321 (85.15%)
      Highest education
       Primary School30 (7.96%)
       Diploma/High School144 (38.20%)
       Undergraduate125 (33.16%)
       Postgraduate78 (20.69%)
      Marital status
       Married270 (71.62%)
       Single107 (28.38%)
      Family size
       Five and below276 (73.21%)
       Six and above101 (26.79%)
      Family income
       below 1000059 (15.65%)
       11000-2000052 (13.79%)
       21000-5000071 (18.83%)
       above 50000195 (51.72%)
      Socio-economic status
       Low28 (7.43%)
       Medium254 (67.37%)
       High95 (25.20%)
      Region of residence
       Eastern98 (25.99%)
       Western40 (10.61%)
       Northern85 (22.55%)
       Southern93 (24.67%)
       Central41 (10.88%)
       North-east20 (5.31%)
      Area of residence
       Urban204 (54.11%)
       Rural173 (45.89%)
      Social caste
       Other Backward Caste198 (52.52%)
       Other126 (33.42%)
       Scheduled Caste33 (8.75%)
       Scheduled Tribe20 (5.31%)
      Religion
       Hindu270 (71.62%)
       Muslim54 (14.32%)
       Christian25 (6.63%)
       Sikhs28 (7.43%)
      Of the total respondents, 70 (19%) were willing to participate in COVID-19 vaccine trial, and 151 (40%) intended to accept the vaccine once it was available. Exposure to COVID-19 cases were reported by 199 (53%), 355 (94%) had knowledge about COVID-19 while 308 (82%) had knowledge about development of the vaccine. History of vaccine hesitancy was present in 41 (11%), and 90 (24%) perceived COVID-19 infection as a risk. More than half the participants, 219 (58%) trusted the healthcare system while 164 (44%) did not trust domestic vaccines. [Table 2].
      Table 2Vaccination intention, Knowledge, Vaccine complacency, and Vaccination confidence of the study participants (N = 377).
      Variablesn (%)
      Intend to participate COVID-19 vaccine clinical trial
       Yes70 (18.57%)
       No177 (46.95%)
       Undecided130 (34.48%)
      If Vaccine against Corona virus is available, I will take it
       Yes151 (40.05%)
       No85 (22.55%)
       Undecided141 (37.40%)
      Exposed to COVID-19 cases
       No199 (52.79%)
       Yes178 (47.21%)
      Knowledge about COVID19
       No/Not Sure22 (5.84%)
       Yes355 (94.16%)
      Knowledge about development of the COVID19 vaccine
       No/Not Sure69 (18.30%)
       Yes308 (81.70%)
      History of vaccine hesitancy
       Yes41 (10.88%)
       No336 (89.12%)
      Risk perception
       Yes90 (23.87%)
       No287 (76.13%)
      Trust in the healthcare system
       No158 (41.91%)
       Yes219 (58.09%)
      Trust in domestic vaccines
       Better95 (25.20%)
       Neutral118 (31.30%)
       Worse164 (43.50%)
      On logistic regression analysis, the odds of intending to participate in COVID-19 vaccine trial were higher among men (aOR: 3.69 [95% CI: 1.51–8.97], p = 0.004) and those having knowledge regarding COVID-19 vaccine development (aOR: 3.05 [95% CI: 1.18–7.88], p = 0.02). Those who trusted domestic vaccines and graduates were less likely to participate in a vaccine trial, aOR of 0.32 (95% CI: 0.12–0.85), and 0.42 (95% CI: 0.20–0.87) respectively. The association was statistically significant (p < 0.05). [Table 3].
      Table 3Factors associated with willingness to participate clinical trial of COVID-19 vaccine among community health workers, India (N = 377).
      VariableOR [95% CI]aOR [95% CI]P-value
      Exposed to COVID-19 cases
       NoRefRef
       Yes1.23 [0.731, 2.068]1.727 [0.922, 3.233]0.088
      Knowledge about COVID-19 virus
       NoRefRef
       Yes1.027 [0.336, 3.136]0.997 [0.295, 3.367]0.996
      Knowledge on development of COVID19 vaccine
       NoRefRef
       Yes1.921 [.874, 4.225]3.049 [1.180, 7.877]0.021
      History of vaccine hesitancy
       YesRefRef
       No2.261 [.778, 6.566]2.053 [0.643, 6.554]0.225
      Risk perception
       NoRefRef
       Yes1.316 [0.693, 2.496]2.027 [0.908, 4.526]0.085
      Trust in the healthcare system
       NoRefRef
       Yes1.101 [0.649, 1.869]1.207 [0.662, 2.202]0.539
      Trust in domestic vaccines
       WorseRefRef
       Better0.547 [0.254, 1.180]0.320 [0.121, 0.847]0.022
       Neutral1.658 [.934, 2.943]1.631 [0.795, 3.348]0.182
      Age
       18-29RefRef
       30-490.661 [0.387, 1.131]0.756 [0.277, 2.061]0.585
      Gender
       FemaleRefRef
       Male1.577 [0.807, 3.082]3.685 [1.513, 8.974]0.004
      Marital status
       MarriedRefRef
       Single1.648 [0.953, 2.849]1.261 [0.446, 3.569]0.662
      Highest education
       Primary/High SchoolRefRef
       Undergraduate0.477 [0.240, 0.948]0.418 [0.201, 0.869]0.019
       Postgraduate1.721 [0.931, 3.182]1.672 [0.819, 3.415]0.158
      Socio-economic status
       LowRefRef
       Medium0.963 [.347, 2.673]0.474 [0.152, 1.477]0.198
       High1.305 [0.442, 3.850]0.492 [0.145, 1.673]0.256
      Area of residence
       UrbanRefRef
       Rural0.923 [0.547, 1.557]0.915 [0.521, 1.606]0.758
      OR- Odd's Ratio, aOR – adjusted odd's ratio, CI – Confidence interval.
      Participants who intended to uptake the hypothetical vaccine were less likely to know about COVID19 virus (aOR: 0.32[95% CI: 0.12–0.88], p value = 0.03). Men were 2.39 (95% CI: 1.17–4.88) times more inclined to get vaccinated. The association was statistically significant (p value = 0.02). The odds of participants to get vaccinated was 2.04 (95% CI: 1.24–4.31) times more among those who perceived COVID-19 as a risk. (p = 0.009) [Table 4].
      Table 4Factors associated with the intention to receive COVID-19 vaccine among community health workers, India (N = 377).
      VariableOR [95% CI]aOR [95% CI]P-value
      Exposed to COVID-19 cases
       NoRefRef
       Yes1.178 [.780, 1.780]1.330 [0.818, 2.163]0.250
      Knowledge about COVID-19 virus
       NoRefRef
       Yes0.3591 [0.146, 0.878]0.317 [0.115, 0.875]0.027
      Knowledge on development of COVID19 vaccine
       NoRefRef
       Yes1.422 [0.821, 2.463]1.459 [0.766, 2.779]0.251
      History of vaccine hesitancy
       YesRefRef
       No2.053 [0.643,6.554]2.038 [0.862, 4.819]0.105
      Risk perception
       NoRefRef
       Yes3.056 [1.370, 6.816]2.308 [1.237, 4.305]0.009
      Trust in the healthcare system
       NoRefRef
       Yes1.604 [1.049, 2.452]1.292 [0.807, 2.068]0.286
      Trust in domestic vaccines
       WorseRefRef
       Better1.085 [0.643, 1.831]0.532 [0.274, 1.033]0.062
       Neutral1.607 [0.992, 2.602]1.241 [0.700, 2.200]0.461
      Age
       18-29RefRef
       30-490.944 [0.608, 1.465]0.649 [0.301, 1.403]0.272
      Gender
       FemaleRefRef
       Male1.479 [0.836, 2.616]2.386 [1.167, 4.878]0.017
      Marital status
       MarriedRefRef
       Single1.063 [0.674, 1.678]0.948 [0.424, 2.121]0.897
      Highest education
       Primary/High SchoolRefRef
       Undergraduate1.205 [0.757, 1.919]1.168 [0.702, 1.945]0.550
       Postgraduate0.7008 [0.398, 1.231]0.612 [0.318, 1.181]0.143
      Socio-economic status
       LowRefRef
       Medium0.819 [0.3676, 1.825]0.578 [0.240, 1.389]0.220
       High1.868 [0.791, 4.413]1.298 [0.511, 3.298]0.584
      Area of residence
       UrbanRefRef
       Rural0.987 [0.652, 1.492]1.004 [0.643, 1.568]0.987
      OR- Odd's Ratio, aOR – adjusted odd's ratio, CI – Confidence interval.

      4. Discussions

      This study is first of its kind to depict the COVID-19 vaccination intention and intention to participate in clinical trial of COVID-19 vaccine among community health workers in India. Of the 377 CHWs, less than half responded positively regarding intention to uptake COVID-19 vaccination, while not even a quarter intended to volunteer for vaccine clinical trial. Knowledge about COVID-19 virus, perception of risk, and gender affected intention to get vaccinated. Gender, and knowledge regarding COVID-19 vaccine development positively affected the willingness to participate in a vaccine trial, while trust in domestic vaccines, and higher educational status were identified as deterrents for the same.
      While around one-third of the study participants reported being undecided regarding their vaccination intention, four in ten CHWs intended to get vaccinated. This level of acceptance, however, will not be sufficient to break the chain of transmission.
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      Motivation for participating in phase 1 vaccine trials: comparison of an influenza and an Ebola randomized controlled trial.
      However, it was not explored in our study.
      This is the first study as per our knowledge which has examined the intention to accept COVID-19 vaccine, and intention to participate in vaccine clinical trial among community health workers in India. However, it has a number of limitations. First, The predictors of vaccine uptake may not be causal owing to the cross-sectional nature of the study, however the identified predictors were in line with potential mechanisms of vaccine acceptance documented in literature. Also, the intention to receive the vaccine may change with time. Second, a convenient snowball sampling was used to recruit participants, which would affect the generalizability of the result. Third, the responses were recorded using an online survey which might have led to potential biases in reporting. Also, questions were available in English language and not in regional languages which might have prevented non-English speaking CHWs from participating.
      Despite almost all participants having knowledge regarding the virus and the development of COVID-19 vaccine, it is of considerable concern that not even half expressed their intention to uptake the vaccine once it's available. In a country like India, where CHWs act as a bridge between the healthcare system and the general population, their recommendation plays an influential role in the general population's vaccination behavior. The grass-root level workers serve as an important source of information for the community, and their perception of COVID-19 vaccination can be a key factor in influencing the public's decision to get vaccinated. The low positive response regarding acceptance of a COVID-19 vaccine among the study participants is worrying. There is a significant need to address the CHW's vaccine related concerns, and develop strategies to increase acceptance rate of COVID-19 vaccine before the undecided make up their mind.

      5. Conclusions

      In this study, we found sub-optimal level of willingness among CHWs to participate in a vaccine trial, and to receive COVID-19 vaccine indicating high levels of vaccine hesitancy. Knowledge about COVID-19 virus, perception of risk, and gender affected intention to get vaccinated. Gender, and knowledge regarding COVID-19 vaccine development positively affected the willingness to participate in a vaccine trial, while trust in domestic vaccines, and higher educational status lowered willingness to participate. Community health workers are trusted influencers and ambassadors of vaccine promotion. Increasing knowledge about COVID-19 disease and the vaccine is not enough to improve vaccine acceptance rates among them. It is important to design evidence-based strategies to promote the uptake of vaccination by addressing vaccine hesitancy. Spreading awareness regarding risks of the disease, demonstrating the effectiveness and safety of vaccines, and addressing gender disparity in vaccine acceptance are essential when rolling out the novel vaccine. These strategies will have implications beyond the current pandemic.

      Sources of support

      None.

      Presentation at a meeting

      No.

      Conflicting interest

      None declared.

      Funding

      This study did not receive any funding from any organization.

      Availability of data and materials

      Data is available upon request.

      Ethics approval and consent to participate

      The study protocol was reviewed and approved by the Institutional Ethical Committee of Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Informed consent was obtained from all participants. Anonymized data was used for interpretation and reporting.

      Consent for publication

      Not applicable.

      Declaration of competing interest

      The authors declare they have no competing interests.

      Acknowledgements

      The authors would like to acknowledge the study participants for their time and contributions to the study.

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