https://orcid.org/0000-0003-2440-6796
ABSTRACT
Healthcare workers (HCWs) are considered both a high-risk population regarding infections and effective vaccine recommenders whose willingness to be vaccinated is the key to herd immunity. However, the vaccination status, acceptance, and knowledge of the 2019 coronavirus disease (COVID-19) vaccine among HCWs remain unknown. Therefore, we conducted an online survey regarding the above among HCWs in China after the vaccine was made available. Questionnaires returned by 1,779 HCWs were analyzed. Among these participants, 34.9% were vaccinated, 93.9% expressed their willingness to receive the COVID-19 vaccine, and vaccine knowledge level was high (89.2%). A bivariate analysis found that participants with a college degree, low level of knowledge, non-exposure to COVID-19 status, and those who are females or nurses have a lower vaccination rate, while participants who are married, with a monthly income of more than 5,000 yuan, and low knowledge levels are less willing to be vaccinated. A multivariate analysis found that participants with a high (OR = 7.042, 95% CI = 4.0918–12.120) or medium (OR = 3.709, 95% CI = 2.072–6.640) knowledge level about COVID-19 vaccines were more willing to be vaccinated. Participants were less likely to accept a COVID-19 vaccine if they were married (OR = 0.503, 95% CI = 0.310–0.815). In summary, Chinese HCWs have a strong willingness to be vaccinated and a high level of knowledge. Measures, such as targeted education for HCWs with low willingness and low level of knowledge, open vaccine review procedures, increased government trust, reduced vaccine costs, and provide vaccination guarantee policies, may improve the vaccination coverage of the at-risk group.
Introduction
On March 11, 2020, the World Health Organization (WHO) characterized the 2019 coronavirus disease (COVID-19) as a pandemic. Citation1 The huge burden of morbidity and mortality caused by the COVID-19 pandemic, as well as the severe social and economic disruptions around the world, are continuing.Citation2 As of the 25th of March 2021, 223 countries around the world are suffering from COVID-19, which has infected more than 120 million people and caused 2.7 million deaths.Citation1 The successful development and use of vaccines may be a key safeguard against COVID-19.Citation3 Additionally, as of January 29, 2021, there are more than 290 COVID-19 vaccine candidates worldwide, about 70 of which have entered clinical evaluation,Citation4 and as of February 19, 2021, 29 countries have disclosed the use of a COVID-19 vaccine.Citation5 One day when the supply is sufficient, people’s willingness to vaccinate will be an important guarantee for improving the coverage of vaccination.
Healthcare workers (HCWs) are among the high-risk groups of contracting and spreading infectious diseases.Citation6 During the COVID-19 pandemic, a large number of medical staff was infected.Citation7 In the United States, 55% of HCWs who have been in contact with COVID-19-infected patients say that health care exposure is the only way of transmission.Citation8 Furthermore, HCWs are generally considered the most reliable source of vaccination information.Citation9 Studies have found that the HCWs’ recommendations play a significant role in increasing the public’s vaccination rate.Citation10 Therefore, the vaccination coverage of HCWs has an important impact on reducing the spread of diseases and promoting the public’s acceptance of vaccines. Although the vaccination policies of different countries differ, HCWs are usually listed as a priority group for receiving a COVID-19 vaccine. So far, studies have reported the willingness of HCWs to receive COVID-19 vaccines,Citation11,Citation12 but most of them were carried out before the vaccines were rolled out. Very few studies examine the HCWs’ vaccination statuses and levels of vaccine knowledge. It is still unknown whether HCWs can reach the expected vaccination coverage in the first place.
Vaccine hesitancy, which is defined as a delay in accepting or refusing vaccination, was considered one of the top ten global health threats in 2019.Citation13 It is also an obstacle to comprehensive vaccination against COVID-19.Citation14 Thirty-nine percent of Americans say they may or never accept the COVID-19 vaccine.Citation15 Although HCWs are considered effective interveners in response to vaccine hesitation, they may have vaccine hesitation themselves because of lack of vaccine knowledge.Citation12 Following a meta-analysis of 20 studies, 14 studies we found that the influenza vaccination coverage of HCWs was less than 50%.Citation16 Under the COVID-19 pandemic, understanding the causes of vaccine hesitation among HCWs will help implement interventions that can ensure high vaccination rates.
China is one of the first countries to suffer from COVID-19 and one of the earliest to develop a COVID-19 vaccine.Citation17 On December 15, 2020, vaccinations for high-risk occupational employees were launched,Citation18 and on December 30, 2020, the China State Food and Drug Administration conditionally licensed the marketing of Sinopharm’s inactivated COVID-19 vaccine.Citation19 By February 3, 2021, over 31 million COVID-19 vaccine doses had been administered to the Chinese public.Citation19 As of February 20, 2021, the total number of vaccinations in China ranks second highest globally.Citation20 However, there is still a big gap with the expected herd immunity coverage. In the last decade, due to vaccine accidents and scandals,Citation21 China’s influenza vaccine intake (25%) has remained far lower than those of developed countries.Citation22,Citation23 What is worrying is that the COVID-19 vaccination volume cannot meet the requirements of herd immunity. Since there are few studies on the COVID-19 vaccination status and knowledge levels, and because the COVID-19 vaccines used in different countries may be different, we designed our own questionnaire to investigate the vaccination statuses, as well as levels of knowledge about and acceptance of these vaccines among Chinese HCWs. Additionally, we determined the influencing factors of vaccination willingness so as to provide useful information for improving the vaccination coverage of such high-risk groups.
Methods
Study population
A cross-sectional survey on HCWs’ vaccination status, acceptance, and knowledge of COVID-19 vaccines was conducted from January 20 to February 20, 2021. The target population comprised Chinese HCWs, including doctors, nurses, ancillary staff, and other personnel working in hospitals. Interns and further evaluations of medical students were not included in the study. All participants gave their informed consent for their inclusion in the study. This study was approved by the Ethics Committee of the Second Affiliated Hospital of Guangxi Medical University.
Survey measures
The final questionnaire on HCWs’ vaccination status, acceptance, and knowledge of COVID-19 vaccines was formed through literature review,Citation24 expert interviews, and pre-surveys. The questionnaire comprised four parts: (1) demographic characteristics (gender, age, ethnicity, highest education, professional title, etc.) and contact experience of COVID-19 cases; (2) whether the participant has been vaccinated against COVID-19; (3) whether the participant is willing to accept the COVID-19 vaccine and their respective reasons; and (4) the participant’s knowledge level of the COVID-19 vaccine. The first draft of the vaccine knowledge questionnaire included 15 items. It was formulated by members of the research team after inquiring about COVID-19 vaccine knowledge from the official website of the Chinese Center for Disease Control and Prevention.Citation25,Citation26 After expert interviews regarding questionnaire content (conducted by 2 chief physicians at the Infectious Diseases and 2 chief physicians at the Respiratory Medicine), the deletion of 2 questions about the mechanism of vaccine action and the type of vaccine (respectively because it is too complicated and there are more than one COVID-19 vaccine currently on the market). Before the survey was formally rolled out, 30 HCWs were randomly selected for a pre-survey to check the internal consistency of the questionnaire. The results indicated Cronbach’s α of 0.869. The final questionnaire consisted of 13 closed-ended questions (including on the recommended target population, vaccination methods, effects and possible adverse reactions) that could be answered with “yes” or “no.” The correct answer rate was used to assess the participant’s knowledge level of the COVID-19 vaccine (possible range = 0.0%–100.0%). The correct answer rate was defined as high (> 85%), medium (60%–85%), and low (< 60%).
Data collection
WeChat, the most popular social media platform in China, was used as an online survey tool for this study. Each participant took approximately five minutes to complete the survey. A mixed sampling process was used (i.e., convenience and snowball samplings). HCWs were selected through convenient sampling. Subsequently, all participants were encouraged to share the survey link with HCWs across the country. One WeChat ID could only be used once to fill out a questionnaire, and only after all questions had been answered could the questionnaire be submitted. The data results and quality of the questionnaire submissions were double-checked.
Statistical analysis
We used IBM SPSS version 22.0 to analyze the data. Categorical variables were expressed as frequencies (percentages). We used bivariate analysis to compare participants who were vaccinated and those not vaccinated, and those accepting and those not accepting the COVID-19 vaccine. Variables with p < .10 in the bivariate analysis were included in the multivariate analysis. A multivariate logistic regression analysis was used to analyze the independent factors influencing COVID-19 vaccination acceptance. All analyses were based on two-sided p-values, and statistical significance was set at p < .05.
Results
Participant characteristics
A total of 1,862 questionnaires were collected, 63 questionnaires were excluded due to low quality, resulting in the final analysis including 1,779 surveys (with a valid response rate of 95.5%). Most participants were female (88.2%), Han nationality (63.9%), nurses (74.0%), and had undergraduate degree (70.2%). About half of the participants were married (59.4%) and had a personal monthly income of 5001–10000 yuan. Participants aged 18–29, 30–39, 40–49 and 50–57 occupied 41.7%, 41.3%, 14.2% and 2.8% () of the total sample.
Table 1. Bivariate correlation of COVID-19 vaccination status of HCWs
COVID-19 vaccination status
Among the 1,779 participants, 621 HCWs had been vaccinated with a COVID-19 vaccine (at least one injection, vaccination rate 34.9%). The participants showed lower vaccination rates if they are female (OR = 0.682, 95% CI: 0.509–0.914), nurses (OR = 0.519, 95% CI: 0.403–0.670), and have not been in contact with suspected or confirmed cases of COVID-19 (OR = 0.527, 95% CI: 0.367–0.756). Participants with undergraduate degrees (OR = 1.743, 95% CI: 1.289–2.358) or postgraduate degrees (OR = 2.286, 95% CI: 1.576–3.316), and with high (OR = 6.807, 95% CI: 3.624–12.788) or medium (OR = 3.455, 95% CI: 1.793–6.655) knowledge level had higher vaccination rates ().
HCWs, healthcare workers; OR, odds ratio; CI, confidence interval; ref., reference group; Knowledge level: The rate of correct answers was defined as high (> 85%), medium (60%–85%), and low (< 60%).*p< .05; **p< .01.
Acceptance of a COVID-19 vaccine and influencing factors
Of these participants, 93.9% (1670/1,779) replied that they accept a COVID-19 vaccine (participants who have been vaccinated were deemed accepting the vaccine). However, 6.1% (109/1,158) of the participants did not want to be vaccinated. A bivariate analysis revealed that participants who were married (OR = 0.498, 95% CI: 0.319–0.779), and had a personal monthly income of 5000–1000 yuan (OR = 0.494, 95% CI: 0.313–0.780) or more than 10,000 yuan (OR = 0.423, 95% CI: 0.213–0.841) were less willing to accept vaccines. Participants who were Ethnic minority (OR = 1.6, 95% CI: 1.034–2.475), with high (OR = 6.147, 95% CI: 3.641–10.37) or medium (OR = 3.150, 95% CI: 1.795–5.529) knowledge levels were more likely to accept a COVID-19 vaccine ().
Table 2. Bivariate correlation of COVID-19 vaccination acceptance of HCWs
HCWs, healthcare workers; OR, odds ratio; CI, confidence interval; ref., reference group; Knowledge level: The rate of correct answers was defined as high (> 85%), medium (60%–85%), and low (< 60%).*p< .05; **p< .01.
We took the willingness to accept a COVID-19 vaccine as the dependent variable. A multivariate logistic regression analysis was performed with ethnicity, marital status, personal monthly income, and knowledge level as independent variables. We assigned a value of ‘1ʹ for ‘accepting COVID-19 vaccine’ and a value of ‘0ʹ for ‘not accepting COVID-19 vaccine.’ The results showed that marital status and knowledge level are independent factors influencing HCWs’ acceptance of a COVID-19 vaccine. Participants with high (OR = 7.042, 95% CI = 4.0918–12.120) or medium (OR = 3.709, 95% CI = 2.072–6.640) knowledge level about a COVID-19 vaccine were more willing to be vaccinated. Participants were less likely to accept a COVID-19 vaccine if they were married (OR = 0.503, 95% CI = 0.310–0.815) ().
Table 3. Multivariable correlates of COVID-19 vaccination acceptance of HCWs
HCWs, healthcare workers; OR, odds ratio; CI, confidence interval; ref., reference group; Knowledge level: The rate of correct answers was defined as high (> 85%), medium (60%–85%), and low (< 60%).*p< .05; **p< .01.
Reasons for accepting or not accepting a COVID-19 vaccine
Occupations putting them at a high risk of contracting COVID-19 (79.9%), vaccines being the most effective means of preventing the disease (68.3%), and worried about contracting the COVID-19 (59.0%) were reported as the main reasons for vaccine acceptance. Conversely, facts regarding the newness of the vaccine and length of time it takes time to “wait and see” (49.5%), as well as the vaccine’s safety (37.6%) and efficacy (33.0%) were the primary reasons why participants were reluctant to be vaccinated ().
Figure 1. Reasons for accepting and not accepting a COVID-19 vaccine.
Knowledge about a COVID-19 vaccine
The rate of correct answers on COVID-19 vaccine knowledge was 89.2%. Social platforms such as WeChat or Weibo (90.1%), websites (87.8%), and TV (77.9%) were the main channels through which people learned about COVID-19 vaccines. Questions regarding the need to wear masks in public after vaccination, people who are currently prioritized for vaccination, and observation time after injection had the highest rate of correct answers. The questions with the lowest correct rates were those regarding the time to produce an immunity effect after vaccination, the time during which antibodies could still maintain a high level, and the interval time between injections ().
Table 4. The response of HCWs to questions related to COVID-19 vaccine knowledge
Discussion
Our study showed that 34.9% of the participants received a COVID-19 vaccine, 93.9% expressed willingness to accept the vaccine, and that the rate of correct answers on COVID-19 vaccine knowledge questions was 89.2%. Chinese HCWs showed a strong willingness to be vaccinated and a high level of COVID-19 vaccine knowledge. It can be predicted that the coverage rate of herd immunity among HCWs might be reached first under the condition of sufficient vaccine supply. Our assessment and resultant findings are among the first on COVID-19 vaccine acceptance by HCWs since the COVID-19 vaccine was rolled out. The analysis of the vaccination status of HCWs can better reflect their true vaccination intention and reveal the details of the characteristics of the final vaccinators.
The survey results showed that the COVID-19 vaccination rate among HCWs was 34.9%, revealing that there is still a big gap to be bridged to reach the 70% coverage target proposed by the Chinese National Health Commission.Citation27 This is related to the fact that the survey was conducted shortly after the start of vaccination, and the production of vaccines could not meet the demand.
We also found that the vaccination rate of females was lower than that of males (33.8% vs. 42.9%), which is consistent with the results of previous studies.Citation28,Citation29 According to published data, men are more susceptible to COVID-19, while women are more concerned about the safety of vaccines, which explains the above results.Citation30,Citation31
The vaccination rate of doctors is higher than that of nurses and other HCWs (47.7% vs. 32.1% and 16.2%). Previous studies have shown that doctors are more willing to receive the COVID-19 vaccine than nurses.Citation11,Citation32 The American Nurses Foundation released the results of a survey conducted by 13,000 nurses, that showed only 34% of nurses were willing to receive the COVID-19 vaccine.Citation33 In fact, nurses are at a higher risk of infection because they directly perform sputum suctions, blood draws, and throat swab collections for patients.Citation32 Fortunately, combined with the results of our survey on vaccine acceptance, the entire group of HCWs had a significantly positive attitude toward vaccination. Chinese HCWs tend to follow official recommendations, and they believe that COVID-19 vaccination is a job and/or social responsibility.Citation34 A global survey on the willingness to vaccinate against COVID-19 showed that countries where people highly trust the government would also likely show a stronger willingness to vaccinate.Citation35 Therefore, it is necessary for the health authorities to take measures to increase government trust. Transparently publicizing the vaccine development and approval processes, as well as using official media, public trust institutions and respected health groups such as the Red Cross to publicize vaccination policies can increase government trust.
Moreover, we found that the higher the education level of the participants, the higher the vaccination rate. These results are consistent with those of Lazarus’s research.Citation35 People with higher education always have a better understanding of the value of vaccines in preventing COVID-19. However, the contrary results of HCWs’ willingness to vaccinate in the six regions of Zhejiang, ChinaCitation11 may be due to the different locations of the survey subjects. Participants who had been exposed to confirmed cases of COVID-19 had a higher vaccination rate (49.2% vs. 33.8%). These participants may have a higher personal perceived risk and worry about being infected. Studies have shown that people with a higher personal perceived risk are more willing to be vaccinated with COVID-19.Citation36
In our research, the vaccination rates of HCWs of different genders, occupations, educational backgrounds, and COVID-19 exposures are different, but there is no difference in the vaccination willingness. A difference often exists between intention and behavior, and can even reach 70%.Citation37 The actual vaccination status can better predict the future vaccination coverage. In analyzing the reasons why HCWs were unwilling to be vaccinated, it was found that they still needed time to wait and see how those vaccinated responded to the vaccine. This further shows that people who are willing to vaccinate may hesitate again when the vaccine is available. Countries planning to carry out vaccinations should pay attention to these phenomena. The development of personalized vaccination plans and education, targeted interventions on barriers to vaccination, announcement of vaccination progress through official media, and timely clarification of negative false rumors on social networks can enhance HCWs’ confidence in vaccines.
In our study, 93.9% of Chinese HCWs expressed their willingness to accept a COVID-19 vaccine. The data is higher than the acceptance of the COVID-19 vaccine of HCWs in Poland (82.9%),Citation38 Italy (67%),Citation12 Saudi Arabia (49.71%),Citation29 and Zhejiang, China (79.09%).Citation11 A survey of HCWs in six Asian countries showed similar willingness to be vaccinated (more than 95%).Citation39 Three reasons could explain the observed high rate. First, compared with previous surveys, the COVID-19 vaccine was used in some people, the safety of the vaccine had been confirmed, and people’s confidence in the vaccine had increased; second, with the advent of the vaccine, the government has issued a series of incentive policies, such as free vaccination and free treatment for adverse reactions. Finally, during the investigation, the number of confirmed COVID-19 cases in China had increased compared with the previous period, which may have increased HCWs’ worries about infection.
Additionally, our survey results show that marital status is an independent factor in vaccine acceptance, which has been rarely found in previous studies. Married participants were the least willing to be vaccinated, which may be due to the following reasons. Married people need to support their families, so their social responsibilities are heavier. They worry about the adverse effects of the vaccine making them a burden on their families. At the same time, worrying about the impact of vaccines on fertility and pregnancy may also be why women are reluctant to vaccinate.Citation40 Indeed, compared with non-pregnant women, pregnant women are more susceptible to the adverse effects of COVID-19. Experts encourage pregnant and breastfeeding women to vaccinate, and it is best to complete the vaccination before pregnancy to ensure that they are protected during pregnancy.Citation41,Citation42 Keeping the above situation in mind, the government and health departments should establish a vaccination knowledge base for special populations based on evidence, which people could refer to. At the same time, when formulating vaccination plans and policies, in addition to medical professional issues, social issues must also be considered. Commitment to free treatment of side effects caused by vaccination and encouraging vaccinators to purchase medical insurance may effectively eliminate the worries of the reform community.
Studies have shown that the affordability of vaccines is an important factor in determining vaccination willingness.Citation43,Citation44 Before the vaccine was rolled out, willingness to pay for it had always been the focus of researchers. Previous studies found that people with higher incomes were more willing to be vaccinated.Citation45,Citation46 However, in our study, participants with a monthly income of less than 5,000 yuan had the highest willingness to vaccinate. In a survey conducted on the willingness of 3,934 Chinese HCWs to vaccinate, more than 2,900 of them stated that they could only accept a fee of less than 500 yuan.Citation11As a self-funded vaccine, influenza vaccine only accounts for 2–3% of China’s annual vaccinations.Citation47 Therefore, the government’s free vaccine policy may be the reason for the above results. Moreover, reducing the cost of vaccines, including the cost of vaccines in medical insurance, and even providing free vaccines, may be an important step to increase the willingness of vaccination.
The rate of correct answers on COVID-19 vaccine knowledge among participants was 89.2%, indicating a high knowledge level. There are many investigations on COVID-19 knowledge,Citation40,Citation48 but fewer on COVID-19 vaccine knowledge. Our survey results can provide information for the government and health authorities to develop vaccine training content plans. The medical staff themselves has medical knowledge background and their high degree of attention to vaccines may be the reason for the high accuracy rate.Citation49 Participants with high or medium knowledge levels are seven or three times more likely to receive the COVID-19 vaccine than those with low levels. This is consistent with previous survey results on the relationship between knowledge level and vaccination willingness.Citation50 Studies have found that education increases HCWs’ flu vaccine intake.Citation51 Therefore, personalized education for HCWs of different genders, marital status, and educational background, may improve the effect of education.
High occupational risk is the main reason why HCWs are willing to be vaccinated. Like other vaccination programs, safety and effectiveness are also threats that affect the willingness of COVID-19 vaccination.Citation52 However, the main reason for HCWs’ unwillingness in this study is that they want to wait and see the vaccine’s safety and effectiveness. This may be related to the current vaccination coverage rate, which is still very small. A previous study found that among Chinese who are willing to receive the COVID-19 vaccine, 47% of the study subjects expressed their desire to first observe the side effects of the vaccine before vaccination.Citation53 With the smooth implementation of China’s vaccination plan, the willingness of HCWs in a “wait-and-see” state should be changed; the current Chinese HCWs’ willingness to vaccinate should be even higher soon.
The strengths of our study include the large sample size, participants from across China, and the examination of a wide range of possible correlations. Since the advent of a COVID-19 vaccine, this is one of the first investigations into the knowledge and acceptability of a COVID-19 vaccine among HCWs. However, there are some limitations in that we recruited a convenience sample and that females accounted for a large proportion of the participants, which may cause a certain bias in the results. Further, considering that this study mainly analyzed knowledge level as an influencing factor of vaccination willingness, we did not analyze the influencing factors of vaccine knowledge level. At the same time, since this study is a cross-sectional survey, we cannot observe the dynamic trends.
Conclusions
Chinese HCWs have a strong willingness to receive the COVID-19 vaccine and have a high level of vaccine knowledge. When formulating vaccination plans and providing relevant education, the government and health departments should focus on females, nurses, HCWs married, and those with low-educated and low levels of vaccine knowledge to mitigate the barriers to vaccination willingness. They should also disclose vaccine safety through official channels, establish a knowledge base of vaccines, provide personalized vaccination knowledge and education, increase health expenditures, reduce vaccine costs, provide vaccination medical insurance, and reduce people’s economic and spiritual burdens. In this way, the coverage rate of HCW vaccinations could be improved and herd immunity finally realized.
Disclosure of potential conflicts of interest
The authors declare that they have no known competing financial interests or personal relationships that could have influenced the work reported in this paper. The content is solely the responsibility of the authors and does not necessarily represent the official views of the country.
Acknowledgments
We are grateful to the four chief physicians who revised the knowledge of the COVID-19 vaccine. We would also like to thank all the HCWs who participated in this study and disseminated the questionnaire to others.
Additional information
Funding
References
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