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Factors contributing to coronavirus disease 2019 vaccine hesitancy among healthcare workers in Iran: A descriptive-analytical study

Open AccessPublished:November 18, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101182

      Highlights

      • vaccine hesitancy is moderate to high among HCWs, particularly nurses.
      • COVID-19-related knowledge and history of COVID-19 vaccination as the significant predictors of vaccine hesitancy.
      • Physicians and nurses respectively obtained the lowest and the highest VH scores than other HCW.

      Abstract

      Background

      Despite the easy availability of coronavirus disease 2019 (COVID-19) vaccination services for healthcare workers (HCWs), some of them hesitate about receiving the vaccine. The aim of this study was to assess the factors contributing to COVID-19 vaccine hesitancy (VH) among HCWs in Iran.

      Methods

      This cross-sectional descriptive-analytical study was conducted in 2021–2022. Participants were 551 HCWs selected through systematic random sampling from four leading university hospitals in Zanjan, Iran. A demographic questionnaire and a 36-item COVID-19 VH questionnaire were used for data collection. Data were analyzed using the SPSS software (v. 20) and through the independent-sample t-test, the one-way analysis of variance, and the multiple linear regression analysis.

      Findings

      Participants' age mean was 34.40 ± 7.77 years and most of them were female (65.9%) and married (70.8%) and had university education (88.6%). The mean score of VH was 96.29 ± 12.88 (in the possible range of 36–180), 79.49% of participants had moderate VH, and 17.42% of them had high VH. COVID-19 VH had significant relationship with organizational role, history of chronic disease, COVID-19-related knowledge, history of COVID-19 vaccination, and history of colleagues' or relatives’ death after vaccination (P < 0.05). The significant predictors of COVID-19 VH were COVID-19-related knowledge (ß = −0.113; P = 0.008) and history of COVID-19 vaccination (β = 0.165; P < 0.001).

      Conclusion

      COVID-19 VH among HCWs is moderate to high, nurses have the highest VH, and the significant predictors of VH are COVID-19-related knowledge and history of COVID-19 vaccination.

      Keywords

      1. Introduction

      Coronavirus disease 2019 (COVID-19) has been a major healthcare challenge in the past two years. It appeared in December 2019 in Wuhan, China, as a new type of pneumonia with symptoms such as fever, dry cough, and dyspnea, and rapidly turned into a pandemic in March 11, 2020.
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      • Mosayebi G.
      • Khaki M.
      • Ghazavi A.
      A review of the 2019 novel Coronavirus (Covid-19): immunopathogenesis, molecular biology and clinical aspects.
      By June 12, 2022, the number of COVID-19-afflicted patients and deaths in the world was 540,349,319 and 6,331,268, respectively. In Iran, these numbers were around 7,023,000 and 141,000, respectively.
      • Ting D.S.W.
      • Carin L.
      • Dzau V.
      • Wong T.Y.
      Digital technology and COVID-19.
      These numbers included only individuals with positive PCR test results and false negative PCR test results should also be considered to estimate the actual COVID-19 prevalence and mortality rates. COVID-19 has seriously affected physical, mental, spiritual, and social health at personal, familial, and social levels as well as all financial, social, and cultural activities.
      • Sadati Ahmad Kalateh
      • Lankarani Mohamad Hossein B.
      • Lankarani Kamran Bagheri
      Risk society, global vulnerability and fragile resilience; sociological view on the coronavirus outbreak.
      The effective management of COVID-19 and its consequences needs local and international interventions. Vaccination is one of the most basic interventions to prevent COVID-19 affliction, hospitalization, and mortality and manage its pandemic.
      • Speiser D.E.
      • Bachmann M.F.
      COVID-19: mechanisms of vaccination and immunity.
      Vaccination is effective in the management and eradication of vaccine-preventable diseases only when at least 80% of people are covered.
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      • Matthews P.C.
      • Stoesser N.
      • et al.
      Impact of vaccination on SARS-CoV-2 cases in the community: a population-based study using the UK's COVID-19 Infection.
      Vaccination programs should aim at reducing not only prevalence rate, but also hospitalization and mortality rates. Therefore, all individuals who are at great risk for affliction should be vaccinated irrespective of their age.
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      • Ivy J.S.
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      Association of simulated COVID-19 vaccination and nonpharmaceutical interventions with infections, hospitalizations, and mortality.
      Healthcare workers (HCWs), as the frontline employees in COVID-19 care, are at great risk for COVID-19 and hence, the World Health Organization assigned them the top priority of vaccination.
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      Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services.
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      • Lennane S.
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      Despite the effectiveness of vaccination in significantly reducing the prevalence and severity of COVID-19, some individuals, including HCWs, hesitate about receiving COVID-19 vaccine.
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      • Hökenek N.M.
      • Altıntaş M.M.
      Vaccine hesitancy of health-care workers: another challenge in the fight against COVID-19 in Istanbul.
      COVID-19 vaccine hesitancy (VH) is a prevalent problem with a prevalence rate of 20%–30% among the general population.
      • Murphy J.
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      • Bentall R.P.
      • et al.
      Psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the United Kingdom.
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      • Seror V.
      • Cortaredona S.
      • et al.
      A future vaccination campaign against COVID-19 at risk of vaccine hesitancy and politicisation.
      • Edwards B.
      • Biddle N.
      • Gray M.
      • Sollis K.
      COVID-19 vaccine hesitancy and resistance: correlates in a nationally representative longitudinal survey of the Australian population.
      VH rate among HCWs was 41% in South Africa,
      • Wiysonge C.S.
      • Alobwede S.M.
      • de Marie C Katoto P.
      • et al.
      COVID-19 vaccine acceptance and hesitancy among healthcare workers in South Africa.
      4.4% in Thailand,
      • Sirikalyanpaiboon M.
      • Ousirimaneechai K.
      • Phannajit J.
      • et al.
      COVID-19 vaccine acceptance, hesitancy, and determinants among physicians in a university-based teaching hospital in Thailand.
      and 40.8% in the United States.
      • Yasmin F.
      • Najeeb H.
      • Moeed A.
      • et al.
      COVID-19 vaccine hesitancy in the United States: a systematic review.
      As HCWs are a reliable source of health-related information in families and societies, their VH can negatively affect the process of COVID-19 vaccination and management. Therefore, effective VH management is essential to improve the effectiveness of COVID-19 vaccination programs.
      • Sirikalyanpaiboon M.
      • Ousirimaneechai K.
      • Phannajit J.
      • et al.
      COVID-19 vaccine acceptance, hesitancy, and determinants among physicians in a university-based teaching hospital in Thailand.
      ,
      • Larson H.J.
      • Clarke R.M.
      • Jarrett C.
      • et al.
      Measuring trust in vaccination: a systematic review.
      • Xiao X.
      • Wong R.M.
      Vaccine hesitancy and perceived behavioral control: a meta-analysis.
      • Abbas K.M.
      • Kang G.J.
      • Chen D.
      • Werre S.R.
      • Marathe A.
      Demographics, perceptions, and socioeconomic factors affecting influenza vaccination among adults in the United States.
      VH among HCWs has different contributing factors such as age, gender, perceived COVID-19 severity, perceived personal susceptibility,
      • Sirikalyanpaiboon M.
      • Ousirimaneechai K.
      • Phannajit J.
      • et al.
      COVID-19 vaccine acceptance, hesitancy, and determinants among physicians in a university-based teaching hospital in Thailand.
      ,
      • Larson H.J.
      • Clarke R.M.
      • Jarrett C.
      • et al.
      Measuring trust in vaccination: a systematic review.
      health-related beliefs, conspiracy theory, and concerns over vaccine effectiveness.
      • Xiao X.
      • Wong R.M.
      Vaccine hesitancy and perceived behavioral control: a meta-analysis.
      ,
      • Abbas K.M.
      • Kang G.J.
      • Chen D.
      • Werre S.R.
      • Marathe A.
      Demographics, perceptions, and socioeconomic factors affecting influenza vaccination among adults in the United States.
      Other common contributing factors for VH include organizational role, trust in the religious compatibility of vaccines, perceived benefits of vaccination, belief in the necessity of vaccination to protect others, and considering vaccination as a collective attempt for disease management.
      • Wiysonge C.S.
      • Alobwede S.M.
      • de Marie C Katoto P.
      • et al.
      COVID-19 vaccine acceptance and hesitancy among healthcare workers in South Africa.
      ,
      • Sirikalyanpaiboon M.
      • Ousirimaneechai K.
      • Phannajit J.
      • et al.
      COVID-19 vaccine acceptance, hesitancy, and determinants among physicians in a university-based teaching hospital in Thailand.
      Some studies reported VH as a prevalent culture- and religion-dependent phenomenon.
      • Larson H.J.
      • Clarke R.M.
      • Jarrett C.
      • et al.
      Measuring trust in vaccination: a systematic review.
      ,
      • Abbas K.M.
      • Kang G.J.
      • Chen D.
      • Werre S.R.
      • Marathe A.
      Demographics, perceptions, and socioeconomic factors affecting influenza vaccination among adults in the United States.
      Despite some attempts to determine the reasons for VH, there are still no comprehensive data in this area, particularly in Iran. Therefore, the present study was designed and conducted to narrow this gap. The aim of this study was to assess the factors contributing to COVID-19 VH among HCWs in Iran.

      2. Methods

      2.1 Design

      This cross-sectional descriptive-analytical study was conducted from August 2021 to January 2022.

      2.2 Participants and setting

      Study population consisted of all 8000 HCWs with or without the history of COVID-19 vaccination in four leading hospitals affiliated to Zanjan University of Medical Sciences, Zanjan, Iran. Based on the population size and with a confidence level of 0.05, an estimated VH prevalence rate of 50%, and a precision value of 0.04, sample size was determined to be 500 and was increased to 551 due to a potential attrition rate of 10%.
      For sampling, the number of participants to be selected from each hospital was determined based on the total number of HCWs in that hospital. Then, sampling interval was determined and HCWs were randomly selected to the study through the name list of HCWs and systematic random sampling.

      2.3 Instruments

      Data collection instruments were a demographic questionnaire and a COVID-19 VH questionnaire. The items of the demographic questionnaire were on age, gender, work experience, educational level, organizational role, history of direct care provision to patients with COVID-19, history of influenza vaccination, COVID-19-related knowledge, history of affliction by COVID-19, history of COVID-19 vaccination, relatives' or colleagues' death due to COVID-19, and relatives' or colleagues’ death after COVID-19 vaccination.
      The COVID-19 VH questionnaire was a researcher-made questionnaire with 36 items. The three main subscales of this questionnaire were inaccurate understanding of COVID-19 (items 1–8, 10, 12, and 13), inaccurate understanding of COVID-19 vaccine and its side effects (items 9, 11, and 14–32), and sociocultural barriers to COVID-19 vaccination (items 33–36). Items were scored on a five-point scale from 1 (“Completely disagree”) to 5 (“Completely agree”). The possible total score of the questionnaire was 36–180 with higher scores showing higher VH. The total score was classified and interpreted as follows: 36–72: low VH; 73–108: moderate VH; and 109–180: high VH. Items were generated through reviewing the existing literature
      • Edwards B.
      • Biddle N.
      • Gray M.
      • Sollis K.
      COVID-19 vaccine hesitancy and resistance: correlates in a nationally representative longitudinal survey of the Australian population.
      • Wiysonge C.S.
      • Alobwede S.M.
      • de Marie C Katoto P.
      • et al.
      COVID-19 vaccine acceptance and hesitancy among healthcare workers in South Africa.
      • Sirikalyanpaiboon M.
      • Ousirimaneechai K.
      • Phannajit J.
      • et al.
      COVID-19 vaccine acceptance, hesitancy, and determinants among physicians in a university-based teaching hospital in Thailand.
      • Yasmin F.
      • Najeeb H.
      • Moeed A.
      • et al.
      COVID-19 vaccine hesitancy in the United States: a systematic review.
      • Larson H.J.
      • Clarke R.M.
      • Jarrett C.
      • et al.
      Measuring trust in vaccination: a systematic review.
      ,
      • Barello S.
      • Nania T.
      • Dellafiore F.
      • Graffigna G.
      • Caruso R.
      ‘Vaccine hesitancy’among university students in Italy during the COVID-19 pandemic.
      • Dror A.A.
      • Eisenbach N.
      • Taiber S.
      • et al.
      Vaccine hesitancy: the next challenge in the fight against COVID-19.
      • Dubé E.
      • Laberge C.
      • Guay M.
      • Bramadat P.
      • Roy R.
      • Bettinger J.
      Vaccine hesitancy: an overview.
      • Dubé E.
      • Vivion M.
      • MacDonald N.E.
      Vaccine hesitancy, vaccine refusal and the anti-vaccine movement: influence, impact and implications.
      • Karafillakis E.
      • Dinca I.
      • Apfel F.
      • et al.
      Vaccine hesitancy among healthcare workers in Europe: a qualitative study.
      • Kestenbaum L.A.
      • Feemster K.A.
      Identifying and addressing vaccine hesitancy.
      • Kose S.
      • Mandiracioglu A.
      • Sahin S.
      • Kaynar T.
      • Karbus O.
      • Ozbel Y.
      Vaccine hesitancy of the COVID‐19 by health care personnel.
      • Loomba S.
      • de Figueiredo A.
      • Piatek S.J.
      • de Graaf K.
      • Larson H.J.
      Measuring the impact of COVID-19 vaccine misinformation on vaccination intent in the UK and USA.
      • Sallam M.
      • Dababseh D.
      • Eid H.
      • et al.
      High rates of COVID-19 vaccine hesitancy and its association with conspiracy beliefs: a study in Jordan and Kuwait among other arab countries.
      • Shaw J.
      • Hanley S.
      • Stewart T.
      • et al.
      Healthcare Personnel (HCP) Attitudes about Coronavirus Disease 2019 (COVID-19) Vaccination after Emergency Use Authorization.
      and ten experts in COVID-19 care and psychometric evaluation were asked to assess the content validity of the questionnaire. The content validity ratio and index values of the items were respectively 0.81–1 and 0.9–1, confirming the acceptable content validity of the questionnaire. Internal consistency assessment also confirmed the acceptable reliability of the questionnaire with a Cronbach's alpha of 0.89. Participants personally completed the study instruments in the presence of the second author.

      2.4 Data analysis

      Data were analyzed using the SPSS software (v. 20). Data description was done through the measures of descriptive statistics, namely frequency, mean, and standard deviation. The Kolmogorov-Smirnov test indicated the normality of the data and thus, the independent-sample t-test, the one-way analysis of variance, and the multiple linear regression analysis with the Enter method were performed to analyze the data. The level of significance was set at less than 0.05.

      2.5 Ethical considerations

      This study has the approval of the Ethics Committee of Zanjan University of Medical Sciences, Zanjan, Iran (code: IR.ZUMS.REC.1400.267). Participants were provided with explanations about the study aim and were informed that participation in and withdrawal from the study would be voluntary and data collection and analysis would be confidential. Informed consent was also got from all of them. Consent to publish has been received from all participants.

      2.6 Findings

      A total of 551 HCWs participated in this study. Their age mean was 34.40 ± 7.77 years and most of them were female (65.9%) and married (70.8%), had university education (88.6%), and had received COVID-19 vaccine (94.6%) (Table 1).
      Table 1Participants’ demographic characteristics and their relationships with COVID-19 vaccine hesitancy.
      CharacteristicsN (%)Mean ± SDTest valueP value
      GenderMale188 (34.1)95.43 ± 13.8021.2870.257
      Female363 (65.9)96.74 ± 12.375
      Marital statusSingle161(29.2)96.45 ± 13.790.034.855
      Married390(70.8)96.23 ± 12.50
      Educational levelBelow diploma10(1.80)96.9 ± 11.650.6430.526
      Diploma53(9.60)98.17 ± 12.05
      University488(88.6)96.07 ± 12.99
      Organizational rolePhysician22(4)85.50 ± 10.577.60<0.001
      Nurse232(42.1)97.92 ± 10.54
      Other clinical workers144(26.1)94.60 ± 13.18
      Non-clinical workers153(27.8)96.96 ± 12.58
      History of chronic diseaseYes31(5.6)91.84 ± 14.613.9440.048
      No520(94.4)96.56 ± 12.73
      Direct care provision to patients with COVID-19Yes370(67.2)96.69 ± 12.711.080.299
      No181(32.8)95.48 ± 13.22
      History of influenza vaccinationYes249(45.2)95.38 ± 12.522.2670.133
      No302(54.8)97.04 ± 13.13
      COVID-19-related knowledgeLow37(6.7)103.41 ± 12.686.5780.002
      Moderate312(56.6)96.19 ± 11.65
      High202(36.7)95.15 ± 12.30
      History of affliction by COVID-19Yes276(50.1)96.66 ± 12.880.4530.501
      No275(49.9)95.92 ± 12.89
      History of COVID-19 vaccinationYes521(94.6)95.72 ± 12.6219.53<0.001
      No30(5.4)106.23 ± 12.71
      Colleagues' or relatives' death due to COVID-19Yes196(35.6)96.14 ± 12.900.040.842
      No355(64.4)96.37 ± 12.88
      Colleagues' or relatives' death after COVID-19 vaccinationYes74(13.4)99.47 ± 14.275.250.022
      No477(86.6)95.82 ± 12.59
      The mean score of VH was 96.29 ± 12.88, 79.49% of participants had moderate VH, and 17.42% of them reported high VH. The mean scores of the VH subscales were 25.27 ± 5.77 for inaccurate understanding of COVID-19, 61.22 ± 9.83 for inaccurate understanding of COVID-19 vaccine and its side effects, and 9.78 ± 2.47 for sociocultural barriers to COVID-19 vaccination (Table 2). The one-way analysis of variance showed significant relationship between VH and organizational role (P < 0.001) and the Bonferroni's post hoc method revealed that physicians and nurses respectively obtained the lowest and the highest VH scores than other participants (P < 0.001).
      Table 2The mean score and level of COVID-19 vaccine hesitancy.
      Hesitancy subscalesMean ± SD
      Total96.29 ± 12.88
      Inaccurate understanding of COVID-1925.27 ± 5.77
      Inaccurate understanding of COVID-19 vaccine and its side effects61.22 ± 9.83
      Sociocultural barriers to COVID-19 vaccination9.78 ± 2.47
      Hesitancy levelN (%)
      Low (scores 36–72)17(%3.08)
      Moderate (scores 73–108)438(%79.49)
      High (scores 109–180)96(%17.42)
      The independent-sample t-test showed that the mean score of VH among participants with no chronic disease, lower COVID-19-related knowledge, no history of COVID-19 vaccination, and history of colleagues' or relatives’ death after vaccination was significantly higher than their counterparts (P < 0.05).
      The results of the multiple regression analysis with the Enter method showed that the significant predictors of COVID-19 VH were COVID-19-related knowledge (ß = −0.113; P = 0.008) and history of COVID-19 vaccination (β = 0.165; P < 0.001) (Table 3).
      Table 3The results of the multiple linear regression analysis to determine the predictors of COVID-19 VH
      Independent variablesBSEBetatP value
      Age0.0980.1650.0580.5910.555
      Work experience−0.0530.168−0.031−0.3150.753
      Gender1.6551.2160.0611.3610.174
      Marital status0.0081.3140.0000.0060.995
      Educational level−1.1781.544−0.036−0.7630.446
      Organizational role0.7320.7150.0511.0240.306
      History of chronic disease4.6162.4020.0831.9220.055
      Direct care provision to patients−1.0611.341−0.041−0.7910.429
      Direct care provision to patients with COVID-19−1.5421.402−0.056−1.1000.272
      History of influenza vaccination1.4331.1130.0551.2870.199
      COVID-19-related knowledge−2.4720.933−0.113−2.6500.008
      History of affliction by COVID-19−0.4941.125−0.019−0.4390.661
      History of COVID-19 vaccination9.3642.4380.1653.8410.000
      Colleagues' or relatives' death due to COVID-190.7161.1900.0270.6020.548
      Colleagues' or relatives' death after COVID-19 vaccination−2.8871.659−0.076−1.7400.082

      3. Discussion

      This study aimed at assessing the factors contributing to COVID-19 VH among HCWs in Iran. Findings revealed that 79.49% of participants had moderate VH and the two significant predictors of VH were COVID-19-related knowledge and history of COVID-19 vaccination. Previous studies reported that the prevalence of VH was 11.4% in Turkey,
      • Janssen C.
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      Hesitancy towards COVID-19 vaccination among healthcare workers: a multi-centric survey in France.
      26% in Malt,
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      COVID-19 vaccine uptake among healthcare workers in the fourth country to authorize BNT162b2 during the first month of rollout.
      28% in Egypt,
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      • Maltezou H.C.
      Attitudes towards vaccination against seasonal influenza of health-care workers in primary health-care settings in Greece.
      28% in France,
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      and 30.7% in Palestine.
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      The higher VH prevalence rate in the present study despite the current strict governmental obligations for vaccination in Iran may be due to the fact that this study was conducted after the dissipation of the delta COVID-19 wave. After the COVID-19 waves, people usually showed limited adherence to COVID-19 prevention protocols and refused vaccination because they believed that a new wave would never happen. Another explanation for the higher VH prevalence in the present study compared with previous studies is that most of those studies assessed individuals' attitudes during the period of COVID-19 vaccine production, testing, and approval, while our participants had free access to COVID-19 vaccination services. Behavior modification is much more difficult than attitude modification and positive attitude about a behavior does not necessarily lead to engagement in that behavior. In fact, vaccination is part of a wider social world and hence, many different factors such as previous health-related experiences, family history, sense of control, and peer opinions can affect individuals’ vaccination-related decisions.
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      and strategies for improving public trust in vaccines should be congruent with the unique political, social, cultural, and financial conditions of each country.
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      Study findings also indicated that physicians had the lowest and nurses had the highest COVID-19 VH. Previous studies also reported significant relationship between organizational role and VH.
      • Kose S.
      • Mandiracioglu A.
      • Sahin S.
      • Kaynar T.
      • Karbus O.
      • Ozbel Y.
      Vaccine hesitancy of the COVID‐19 by health care personnel.
      ,
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      • Maillard A.
      • Bodelet C.
      • et al.
      Hesitancy towards COVID-19 vaccination among healthcare workers: a multi-centric survey in France.
      • Barry M.
      • Temsah M.-H.
      • Aljamaan F.
      • et al.
      COVID-19 vaccine uptake among healthcare workers in the fourth country to authorize BNT162b2 during the first month of rollout.
      • Dedoukou X.
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      • Maragos A.
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      • Maltezou H.C.
      Attitudes towards vaccination against seasonal influenza of health-care workers in primary health-care settings in Greece.
      Two studies also showed that compared with physicians, nurses and nurse assistants had greater VH.
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      Healthcare Personnel (HCP) Attitudes about Coronavirus Disease 2019 (COVID-19) Vaccination after Emergency Use Authorization.
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      • et al.
      Intention to get vaccinations against COVID-19 in French healthcare workers during the first pandemic wave: a cross-sectional survey.
      The highest rate of VH among nurses may be attributed to their risk underestimation,
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      their limited trust in vaccine effectiveness, or their fear over the side effects of vaccines. At the time of this study, there were limited data about the effectiveness of COVID-19 vaccines and about the results of the third rounds of vaccine testing clinical trials. As HCWs with high VH are less likely to encourage their clients to receive COVID-19 vaccine,
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      • et al.
      Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: a systematic review and meta-analysis.
      Given the higher VH among healthy individuals, governmental authorities may need to use some incentives or restrictions to require them to receive vaccine and thereby, improve vaccine coverage and effectiveness. The incentives may include permission for travel, free transportation services to vaccination sites, gift cards, and tickets for sport events and concerts for individuals who receive vaccine. The restrictions may include restriction of occupational activities for individuals with VH. Of course, incentives may be more effective than restrictions because most HCWs disagree with mandatory vaccination.
      • Shaw J.
      • Hanley S.
      • Stewart T.
      • et al.
      Healthcare Personnel (HCP) Attitudes about Coronavirus Disease 2019 (COVID-19) Vaccination after Emergency Use Authorization.
      Contrary to our findings, some studies in different countries reported no significant relationship between affliction by chronic disease and COVID-19 VH.
      • Sallam M.
      COVID-19 vaccine hesitancy worldwide: a concise systematic review of vaccine acceptance rates.
      • Yang J.
      • Zheng Y.
      • Gou X.
      • et al.
      Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: a systematic review and meta-analysis.
      • Andersen K.G.
      • Rambaut A.
      • Lipkin W.I.
      • Holmes E.C.
      • Garry R.F.
      The proximal origin of SARS-CoV-2.
      Our findings also indicated higher COVID-19 VH among HCWs whose colleagues or relatives had died after vaccination. The COVID-19 pandemic and its vaccines were associated with different rumors and inaccurate information in social media. Examples of these rumors and inaccurate information were the relationship of the G5 cellular network with COVID-19, death of participants in COVID-19 vaccine trials after receiving the first dose, and consideration of COVID-19 pandemic and vaccination as biologic weapons. Such inaccurate information can increase skepticism about new vaccines, act as a major barrier to COVID-19 vaccination,
      • Loomba S.
      • de Figueiredo A.
      • Piatek S.J.
      • de Graaf K.
      • Larson H.J.
      Measuring the impact of COVID-19 vaccine misinformation on vaccination intent in the UK and USA.
      ,
      • Andersen K.G.
      • Rambaut A.
      • Lipkin W.I.
      • Holmes E.C.
      • Garry R.F.
      The proximal origin of SARS-CoV-2.
      ,
      • Zhou P.
      • Yang X.-L.
      • Wang X.-G.
      • et al.
      A pneumonia outbreak associated with a new coronavirus of probable bat origin.
      and make individuals attribute ordinary deaths and events to COVID-19. Given the inadequacy of information about COVID-19 vaccines and their effects, further studies are needed to provide accurate and reliable information in this area and deny COVID-19-related rumors.
      Study findings also revealed COVID-19-related knowledge as the significant predictor of COVID-19 VH. In agreement with this finding, previous studies reported that individuals with lower knowledge about COVID-19 and its vaccine had higher VH.
      • Zhang J.
      • While A.E.
      • Norman I.J.
      Knowledge and attitudes regarding influenza vaccination among nurses: a research review.
      ,
      • Griffith J.
      • Marani H.
      • Monkman H.
      COVID-19 vaccine hesitancy in Canada: content analysis of tweets using the theoretical domains framework.
      A study in China also showed that individuals with lower COVID-19-related knowledge had lower trust in official media, paid lower attention to COVID-19-related information, had lower sensitivity to COVID-19 and its relevant protective behaviors, and had greater COVID-19 VH(46). These findings together with the multiplicity of the sources of inaccurate COVID-19-related information highlight the importance of providing accurate and reliable COVID-19-related information in media.
      • Dubé E.
      • Laberge C.
      • Guay M.
      • Bramadat P.
      • Roy R.
      • Bettinger J.A.
      Vaccine hesitancy: an overview.
      History of COVID-19 vaccination was the other significant predictor of COVID-19 VH in the present study so that participants with no history of COVID-19 vaccination had greater VH. Similarly, a study reported that 61.6% of HCWs who had received one dose of COVID-19 vaccine intended to receive the second dose.
      • Zewude B.
      • Belachew A.
      Intention to receive the second round of COVID-19 vaccine among healthcare workers in eastern Ethiopia.
      Previous studies reported limited trust in vaccines and concerns over their side effects as two main predictors of VH.
      • Dror A.A.
      • Eisenbach N.
      • Taiber S.
      • et al.
      Vaccine hesitancy: the next challenge in the fight against COVID-19.
      ,
      • Kose S.
      • Mandiracioglu A.
      • Sahin S.
      • Kaynar T.
      • Karbus O.
      • Ozbel Y.
      Vaccine hesitancy of the COVID‐19 by health care personnel.
      ,
      • Saied S.M.
      • Saied E.M.
      • Kabbash I.A.
      • Abdo S.A.E.
      Vaccine hesitancy: beliefs and barriers associated with COVID-19 vaccination among Egyptian medical students.

      3.1 Study limitations

      This study was conducted on HCWs with an age mean of 34.40 ± 7.77 years and hence, its findings may not be generalizable to adolescents and elderly people.

      4. Conclusion

      This study shows moderate to high VH among HCWs, particularly nurses, and reveals COVID-19-related knowledge and history of COVID-19 vaccination as the significant predictors of VH. Given the significant influence of HCWs on the health-related behaviors of other individuals, healthcare authorities need to employ effective strategies to improve knowledge and vaccine acceptance among professional and non-professional HCWs. Interventional studies are also recommended to evaluate the effects of education on their knowledge and public rumors about COVID-19 vaccine.

      Funding statement

      This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

      Declaration of competing interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      Acknowledgement

      This article was extracted from a Master's thesis in Critical Care Nursing approved by the Social Determinants of Health Research Center of Zanjan University of Medical Sciences, Zanjan, Iran. We are thankful to all HCWs who participated in this study.

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