Knowledge, Attitudes and Acceptance towards COVID-19 Vaccination among Health Care Workers in Mukalla city-YEMEN: an analytical cross-sectional study

doi:10.21203/rs.3.rs-2090470/v1

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Research Article

Knowledge, Attitudes and Acceptance towards COVID-19 Vaccination among Health Care Workers in Mukalla city-YEMEN: an analytical cross-sectional study

https://doi.org/10.21203/rs.3.rs-2090470/v1

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Background

COVID-19 vaccination is one of the greatest public health interventions to reduce the burden of the COVID-19 pandemic. Yemen began on April 2021 to vaccinate healthcare workers for COVID-19 with the vaccine. However, the media's negative portrayal of vaccines safety and efficacy has led to concerns regarding the acceptance of the vaccine. Therefore, our study aimed to assess knowledge, attitudes and acceptance towards COVID-19 Vaccination among HCWs in Mukalla city-Yemen.

Methods

An analytical cross-sectional study was conducted using convenience sampling method in Mukalla city among healthcare workers from April 2022 to May 2022. Data were collected by a self-administered questionnaire. A Chi-square test was used to assess the association between independent variables (demographic) and dependent variables (knowledge, attitude and acceptance). Correlation between knowledge and attitude levels with rate of acceptance was assessed using Pearson correlation coefficient.

Results

449 respondents were included in the final analysis, of which 237 (52.8%) were males and 212 (47.2%) were females, with a mean age ± SD of 31.0 ± 7.6 years. The overall results regarding knowledge, attitude, and acceptance rates of the COVID-19 vaccines were 65.3% 63.7% and 68.8% (with an efficacy of 90%), respectively. Acceptance was statistically associated with participants’ job, vaccination state, whether they were dealing with suspected cases of COVID-19 and their source of COVID-19 related information (p-value < 0.05). level of acceptance was moderately correlated with attitude level (r = 0.527).

Conclusion

Healthcare workers were found to have a moderate level of knowledge and attitude toward COVID-19 vaccination. However, acceptance rate was scaling down according to vaccine efficacy. Many demographic characteristics were significantly associated with acceptance of COVID-19 vaccination.

COVID-19

Vaccination

Healthcare workers

Knowledge

Attitude

Acceptance

The Coronavirus Disease 2019 (COVID-19) is a viral pneumonia outbreak that was first discovered in December 2019 in Wuhan, People's Republic of China ^[1]. A corona virus with symptoms similar to those of severe acute respiratory syndrome (SARS) was discovered in broncho-alveolar lavage samples taken from COVID-19 patients and was named 2019-nCOV. Which is considered the most probable causative agent of the severe pneumonia, COVID-19 is characterized by high grade fever, cough and chest discomfort ^[2]. The primary route of infection of COVID-19 is through aerosolized droplets or airborne transmission ^[3].

In March 2020, the World Health Organization (WHO) declared COVID-19 to be a pandemic ^[4], which consequently had a devastating impact worldwide. As on late December 2020, over 82 million people had contracted COVID-19, and over 1.8 million had died as a result ^[5]. In order to combat the infection, a comprehensive plan was put into action. The global implementation of the action plan aimed to lower COVID-19 morbidity and mortality, through encouraging hand hygiene and physical distancing, as well as, other infection control measures. There was hope for a safe and effective vaccine that would be accessible on the need,^[6] which led to a strong call for developing a vaccination against the new Corona virus, and prompted scientists and pharmaceutical companies across the world to compete against time in an effort to develop a vaccine ^{[7, 8]}.

One of the most effective public health measures to lower the burden of infectious diseases and the associated mortality is vaccination ^[9]. The United States Food and Drug Administration (FDA) approved the first Emergency Use Authorization (EUA) for a COVID-19 vaccine in individuals 16 years of age and older on December 2020 ^[10]. Pfizer-BioNTech The first vaccine to be made available in the United States and throughout the world following EUA approval ^[11]. Within days, other nations followed and gave approval. Of all the vaccines that reached the fourth phase of clinical testing, four were licensed for use. Two vaccines use a mRNA vaccine platform, one uses the novel chimpanzee adenovirus-vectored vaccine platform and the fourth uses an inactivated COVID-19 virus vaccine platform ^{[12, 13, 14]}. Months later, Johnson and Johnson’s Janssen vaccine (J&J/Janssen) was also approved by EUA which uses a modified adenovirus technology ^[15].

The risk of a severe COVID-19 infection has been proven to be reduced by all of the vaccines the EUA has deemed safe and effective. The possible adverse effects of the vaccines include mild side effects such as fever, tiredness, pain and swelling in the injection site, in addition to rare cases that have experienced serious adverse effects such as anaphylaxis, thrombosis with thrombocytopenia syndrome, myocarditis and pericarditis ^{[16, 17]}.

For the purpose of the vaccine to be successful, the vaccines uptake level must be high in order to reduce the transmission and to achieve herd immunity among the general population ^[18]. However, vaccine hesitancy is one of the major challenges facing public health in achieving such a goal ^[19].

The WHO Strategic Advisory Group of Experts (SAGE) defined vaccine hesitancy as ''a delay in acceptance, or refusal of vaccines despite availability of vaccine services" ^[20]. There are several determinants of COVID-19 vaccine hesitancy among healthcare workers (HCWs) such as concerns about vaccine safety which is considered as the most common and important reason of vaccine hesitancy. Moreover, other drivers of COVID-19 vaccine hesitancy include concerns about potential side effects, as well as, beliefs that vaccines have low efficacy and effectiveness against the virus. The rapid development and EUA of COVID-19 vaccines had caused many concerns and led many HCWs to distrust the health system. Lack of knowledge and information about the vaccine was a major influencer on vaccine uptake, which made some HCWs decide to wait for more data to be released, observe its effects on others first, or have trust in their immune system instead of having the vaccine ^[21].

To demonstrate HCW's perspectives, a poll was conducted in the United States showed that (84.6%) of HCWs had the COVID-19 vaccine or were willing to take it, (8.4%) were hesitant but would consider to get it in the future and (3.2%) were not intending to take it at all ^[22]. Another study was carried in Saudi Arabia revealed that (85%) were satisfied with the information they had received about COVID-19 vaccine and (95%) of the same subjects had the vaccine shot, while (92%) would advise their family to take it ^[23]. Another study in Egypt showed that only (21%) of Egyptian HCWs accept COVID-19 vaccines. As a result, vaccine hesitancy represents a major barrier for implementing vaccination programs ^[24].

Since Yemen has a population of over 30 million and lacks a strong surveillance system, it's difficult to know the actual extent of COVID-19 infection. As from January 3, 2020 to 22 July 2022 there were 11,849 confirmed cases and 2149 deaths were reported to WHO ^[25]. Through the COVAX initiative, Yemen received the first patch of AstraZeneca vaccine in April 2021. which was intended for HCWs', patients with chronic illness and the elderly (over 60 years of age) ^[26]. However, only 864,544 COVID-19 vaccines have been administered so far, accounting for 1.5% of the country's total population ^[27].

The media's negative portrayal of the AstraZeneca vaccine safety and efficacy has led to concerns among the health officials, academics and international organizations about the acceptance of the vaccine by Yemeni people and particularly HCWs’ ^[27].

Therefore, in order to preserve and maintain the safety of the health sector, vaccination is considered the most cost-effective method to reach this goal. The knowledge and attitude levels of the HCWs are major factors that affect their vaccination status, which contributes greatly to the public acceptance of vaccination campaigns. Therefore, our study aimed to assess Knowledge, Attitudes and Acceptance towards COVID-19 Vaccination among HCWs in Mukalla city-Yemen.

Study design:

The present study is an analytical cross-sectional study which was conducted by the by research team in Hadhramaut university to assess the knowledge, attitudes and acceptance of COVID-19 vaccination among HCWs in Mukalla city at the period of April 2022 to May 2022.

Study area:

This study was conducted in governmental hospitals in Mukalla city / Yemen. There are two sectors providing healthcare services, the governmental sector and the private sector. The governmental sector is the major provider of healthcare at all levels of services. At present, there are four major governmental hospitals, University Hospital for Gynecology, Obstetrics, and Pediatrics (UHGOP), Mukalla Maternity and Childhood Hospital (MMCH), Ibn Sina General Hospital (ISGH) and Riyadh Al-jariri Hospital for fever and COVID-19 treatment Center (RHFCC).

Study population:

Study population are all HCWs at governmental hospitals in Mukalla city at period between April 2022 to May 2022. According to WHO, there are five broad groupings of HCWs to be distinguished:

Health professionals: Include general medical practitioners, specialist medical practitioners, nurses, midwives, dentists, physiotherapists, nutritionists, pharmacist, and laboratory technicians.
Health associate professionals.: Include ambulance workers, equipment, medical, pathology and pharmaceutical technicians, medical assistants and medical imaging and therapeutic.
Personal care workers in health services.: Include health care assistants and home-based personal care workers.
Health management and support personnel.: Include health service managers, service and sales workers and medical secretaries.
Health service providers not elsewhere classified: Include armed forces occupations^[29].

Inclusion criteria:

All Yemeni HCWs who are willing to participate in the study.

Exclusion criteria:

Non-Yemeni HCWs, nutritionists, dentists, physiotherapists, Health associate professionals, Personal care workers in health services, and Health service providers not elsewhere classified.

Sample size:

We calculated the required sample size by the following formula:

[n= \(\frac{{\mathbf{z}}^{2}\left(\mathbf{p}\mathbf{q}\right)}{{\mathbf{d}}^{2}}\) ] In which:
n = the desired sample size
z = certainly (95% use 1.96)
p = Proportion of characteristics in the population (p = 0.61) according to previous similar study conducted in Yemen ^[28].
q = 1-P (1-0.61) = 0.39
d = Precision of error allowable (D = 5%=0.05)
[n =\(\frac{{1.96}^{2}\left(0.61 \mathbf{x} 0.39\right)}{{0.05}^{2}}= 366\)]

We added 83, so the final sample size is 449 HCW.

Sampling method:

The sample was selected by multistage sampling method as the following:

Firstly, we determined the total number of governmental hospitals in Mukalla city. There are 4 governmental hospitals, as shown in table (1).

Table 1

governmental hospitals in Mukalla city.
	Name of the hospital
1	Ibn Sina General Hospital (ISGH)
2	University Hospital for Gynecology, Obstetrics, and Pediatrics (UHGOP)
3	Mukalla Maternity and Childhood Hospital (MMCH)
4	Riyadh Al-jariri Hospital for fever and COVID-19 treatment center (RHFCC)

Secondly, we selected two hospitals from the total four hospitals by lottery, which are shown in table (2).

Table 2

selected hospitals in Mukalla city.
	Name of the hospital
1	Ibn Sina General Hospital (ISGH)
2	Mukalla Maternity and Childhood Hospital (MMCH)

Thirdly, we determined the total number of HCWs in the two selected hospitals. As shown on table (3).

Table 3

total number of HCWs in selected hospitals.
	Name of the hospital	No. of total HCWs
1	Ibn Sina General Hospital (ISGH)	456
2	Mukalla Maternity and Childhood Hospital (MMCH)	184
Total		640

Fourthly, we distributed the sample size between the selected hospitals according to the total number of HCWs in each hospital, which is calculated as shown in table (4) by the following formulas

Percentage of HCWs in each hospital is calculated by the formula \(\left[\frac{\mathbf{a}}{\mathbf{N}}100\right]\), in which:

a = No. of HCWs in each hospital.
N = Total No. of HCWs in selected hospitals (640).
ISGH= \(\left[\frac{456}{640}100\right]\)=71
MMCH= \(\left[\frac{184}{640}100\right]\)=29

Sample size of HCWs in each hospital is calculated by the formula , in which:

a = No. of HCWs in each hospital.
N = Total No. of HCWs in selected hospitals (640).
n = Sample size (449).
ISGH= \(\left[\frac{456}{640}449\right]\)=320
MMCH= \(\left[\frac{184}{640}449\right]\)=129

Table 4

sample size distribution and percentages among the selected hospitals
Name of the hospital	No. of total HCWs	%	Sample size
Ibn Sina General Hospital (ISGH)	456	71	320
Mukalla Maternity and Childhood Hospital (MMCH)	184	29	129
Total	640	100	449

Fifthly: we determined the ideal sample size distribution among selected hospitals according to HCWs' groupings (generalist medical practitioners, specialist medical practitioners, nurses, midwives, pharmacist, and lab technicians). As shown in table (5).

Table (5): ideal sample size distribution according to HCWs' groupings among selected hospitals.

Name of hospital		Generalist medical practitioner	Specialist medical practitioner	Nurse	Pharmacist	Lab technician	Midwife	Total
IBSGH	Total No.	88	49	224	16	79	0	456
	%	19	11	50	3	17	0	100
	Sample	62	35	159	11	56	0	323
MMCH	Total No.	44	20	39	16	24	41	184
	%	24	11	21	9	13	22	100
	Sample	31	14	27	11	17	29	129
Total sample		93	49	186	20	72	29	449

Sixthly: we selected HCWs from selected hospitals based on convenience sampling method.

Data collection and study tool:

The data was collected by a self-administered questionnaire made by research team in Hadhramaut university which was reviewed by specialists of the academic staff. The questionnaire was developed in English and was forward-backward translated to Arabic (native language in Yemen) and it consists of 4 sections with a total of 33 items.

The first section includes 8 items regarding demographic (gender, age, level of education), workplace (job description) and personal data related to COVID-19 (vaccination state, suspected or confirmed exposure to infected cases, personal history of COVID-19 infection, and source of COVID-19 knowledge).
The second section includes 10 items for assessing HCWs' knowledge.
The third section includes 9 items regarding HCWs' attitudes.
The fourth section includes 6 items regarding HCWs' acceptance.

For statistical analysis, a pilot-study (pre-test) involving 30 HCWs was carried out. A number of revisions were then made in order to guarantee good internal consistency by Cronbach's alpha. The analysis excluded the sample selected for the pilot study. The questionnaire demonstrated an internal consistency with Cronbach's alpha values of (0.713) for the knowledge section, (0.578) for the attitude section, and (0.824) for the acceptance section.

Data analysis:

Statistical Package for the Social Sciences (SPSS) Version 25 was used to code and analyze the data. For the purposes of descriptive analysis, percentage, mean, frequency, and standard deviation (SD) were used. A Chi-square test was utilized to assess the association between independent variables (demographic) and dependent variables (knowledge, attitude and acceptance). variables with p-values < 0.05 were declared as factors significantly associated with accepting to be vaccinated among HCWs. The relation between knowledge and attitude levels with rate of acceptance was assessed using Pearson correlation coefficient.

- The knowledge section: each correct answer is given 1 point, where incorrect answers/ I don't know are given 0 points. Classified as the following:

Excellent knowledge score: > mean + SD,
Good knowledge score: mean − SD to mean + SD.
Poor knowledge score: < mean − SD.

- The attitude section: data are calculated using 2-point scale. Each dependent variable will have three possible values: 2 = positive attitude, 1 = neutral, 0 = negative attitude. Classified as the following:

Positive attitude score: > mean + SD.
Neutral attitude score: mean − SD to mean + SD.
Negative attitude score: < mean − SD.

The acceptance section: the acceptance is measured by accept/refuse. which will be calculated as percentages in regards to the efficacy.

Finally, the data will be presented in tables and graphs using computer applications (Microsoft Word 2016 and Microsoft Excel 2016).

Variables definition:

Dependent variables, which includes:

Knowledge: the state of knowing about or being familiar with a statement in our study.
Attitudes: feelings or opinions about a statement.
Acceptance: is defined as the individual answer either accept or refuse when presented with an opportunity to vaccinate or support vaccination.

Independent variables, which include:

Demographic variables, which include (gender, age, level of education, job description, vaccination state, suspected or confirmed exposure to infected cases, personal history of COVID-19 infection, and source of COVID-19 knowledge).

Ethical approval:

An ethical approval of the project was obtained from Hadhramout University College of Medicine, department of Community Medicine. The study was carefully explained to the participants regarding its nature, objectives and risks or benefits regarding completion of the study. Participation in the study was considered an approval for use of data. We ensure that the data will be stored in a secure place, only to be used for research purposes and allowed to be accessed exclusively by the research team members to assure confidentiality.

The final analysis of the study included 449 HCWs. 237 (52.8%) were males and 212 (47.2%) were females, the age mean ± SD was 31.0 ± 7.6 years. Among the participants, 168 (37.4%) were nurses, 104 (23.2%) were general medical practitioner, 60 (13.4%) were laboratory technicians, 48 (10.7%) were specialist medical practitioners, 37 (8.3%) were midwives and 32 (7.1%) were pharmacists. More than half the respondents had a bachelor degree or higher education 277 (61.7%).

Among study participants, 284 (63.3%) deal directly with suspected cases of COVID-19. However, only 80 participants (17.8%) report being infected with COVID-19 and the majority of HCWs were not vaccinated for COVID-19 310 (69.0%). about half the participant 228 (50.8%) use the World Health Organization (WHO) as their main source of COVID-19 information. Table (6) gives a general overview of the study characteristics.

Table 6

Characteristics of study participants (n = 449)
Variable		Frequency	Percent
Age	20–33 years	334	74.4
	34–47 years	97	21.6
	48–61 years	15	3.3
	62–75 years	3	0.7
Gender	male	237	52.8
Gender	female	212	47.2
Job description	general practitioner	104	23.2
	medical specialist	48	10.7
	nurse	168	37.4
	midwife	37	8.3
	pharmacist	32	7.0
	laboratory technician	60	13.4
Educational degree	diploma	172	38.3
	bachelor	233	51.9
	postgraduate studies	44	9.8
Dealing with suspected COVID-19 cases	yes	284	63.3
Dealing with suspected COVID-19 cases	No	165	36.7
Infected with COVID-19	yes	80	17.8
Infected with COVID-19	no	369	82.2
Vaccination state	complete vaccination	107	23.8
	incomplete vaccination	32	7.2
	not vaccinated	310	69.0
what is your main source of COVID-19 related information?	WHO	228	50.7
	common rumors in society	21	4.7
	family and social media	17	3.8
	news and media	64	14.3
	internet and social media	108	24.1
	Don't have special source	11	2.4

HCWs' Knowledge regarding COVID-19 and COVID-19 vaccination

The majority of HCWs 293 (65.3%) had good knowledge regarding COVID-19 and COVID-19 vaccination, as evident by the mean ± SD score of 6.12 ± 2.08 (ranging from 0 to 10). as shown in figure (1).

Among HCWs, 335 (74.6%) were aware that the elder patients are the most susceptible age group to COVID-19 complications and the majority of HCWs 349 (77.7%) considered COVID-19 as a serious disease with significant complications, in addition, about half of the HCWs were aware of the correct drug use for management of COVID-19 228 (50.8%). Nearly two thirds of HCWs were aware of the presence of different COVID-19 mutations 273 (60.8%). However, the majority of the HCWs were not aware of the safety of lactation during COVID-19 infection 190 (42.3%) or the safety of COVID-19 vaccine during pregnancy 206 (45.9%) which indicates a defect regarding obstetrical knowledge of COVID-19 vaccine. Among HCWs, 188 (41.9%) were aware of COVID-19 vaccine side effect and most of the HCWs were aware of the importance of self-protection methods even after complete vaccination 379 (84.4%). However, only about half of the HCWs 213 (47.4%) were aware of the effectiveness of the vaccine in preventing COVID-19 complications, yet 303 (67.5%) had knowledge of the possibility of being infected with COVID-19 even after complete vaccination. The HCWs’ answers of knowledge questions are demonstrated in table (7) respectively.

Table 7

COVID-19 and COVID-19 vaccination knowledge questions (n = 449)
Question	Answer	Frequency	Percent
In case of transmission, what is the most affected age group?	infants and children (< 18 years)	2	.4
	adults (18–65 years)	99	22.0
	elders (> 65 years)	335	74.6
Is COVID-19 a severe disease that may cause severe complications?	yes.	349	77.7
	No	74	16.5
	I do not know	26	5.8
Are there antibiotics can prevent and/or treat COVID-19?	yes.	135	30.1
	no	228	50.8
	I do not know	86	19.2
Are there any variants or genetic mutations for COVID-19?	yes.	273	60.8
	no	57	12.7
	I do not know	119	26.5
Can COVID-19 positive mothers safely breastfeed their babies?	yes.	122	27.2
	no	137	30.5
	I do not know	190	42.3
Are COVID-19 vaccines safe during pregnancy?	yes.	116	25.8
	no	127	28.3
	I do not know	206	45.9
does COVID-19 vaccination commonly cause severe side effects?	yes.	163	36.3
	no	188	41.9
	I do not know	98	21.8
Are Personal Protection Practices as hand hygiene and social distancing considered important after getting vaccinated for COVID-19?	yes.	379	84.4
	no	48	10.7
	I do not know	22	4.9
can COVID-19 vaccination prevent the disease complication effectively?	yes.	213	47.4
	no	128	28.5
	I do not know	108	24.1
Can COVID-19 be acquired even after complete vaccination?	yes.	303	67.5
	no	52	11.6
	I do not know	94	20.9

HCWs' attitude regarding COVID-19 vaccination

The majority of HCWs had neutral attitude regarding COVID-19 vaccination (286, 63.7%), as evident by the mean ± SD score of 9.26 ± 3.230 (ranging from 0 to 18). as shown in figure (2).

Among HCWs, 221 (49.2%) feel worried of COVID-19 vaccines and 291 (64.8%) believe that natural immunity will last longer compared to immunity gained from the vaccine, as well as, only 130 (29.0%) believe that COVID-19 vaccination is helpful in protecting community's health. Among the HCWs, 172 (38.3%) believe there are dangerous undiscovered side effects and 177 (39.4%) believe that the vaccine is promoted by authorities and media for non-community health related issues. Yet, more than two thirds believe people with chronic and severe diseases should be vaccinated (284, 63.3%) and about half of the HCWs believe health care workers should be vaccinated as well (255, 56.8%). most of the HCWs (363, 80.8%) see that the vaccine should be made available for no cost. However, only 105 (23.4%) would purchase it if it was for sale. The HCWs’ answers of attitude questions are demonstrated in table (8).

Table 8

COVID-19 vaccination attitude questions (n = 449)
Question	Answer	Frequency	Percent
I feel worried about COVID-19 vaccination	Agree	221	49.2
	Natural	144	32.1
	Disagree	84	18.7
I believe that natural immunity will last longer than immunity acquired from COVID-19 vaccine	Agree	291	64.8
	Natural	103	22.9
	Disagree	55	12.2
I see that COVID-19 vaccination is not helpful for most people	Agree	130	29.0
	Natural	188	41.9
	Disagree	131	29.2
although COVID-19 vaccine appears to be safe, there are dangerous problems that we haven't yet discover	Agree	172	38.3
	Natural	205	45.7
	Disagree	72	16.0
believe that authorities and media are promoting COVID-19 vaccine for reasons not related to community health	Agree	177	39.4
	Natural	166	37.0
	Disagree	106	23.6
I think that people with chronic or severe diseases should be vaccinated	Agree	284	63.3
	natural	104	23.2
	disagree	61	13.6
I think health care workers should be vaccinated	Agree	255	56.8
	natural	132	29.4
	disagree	62	13.8
COVID-19 vaccine should be offered to every one for free	Agree	363	80.8
	natural	63	14.0
	disagree	23	5.1
if the COVID-19 vaccine is available for sale I will buy it	Agree	105	23.4
	natural	143	31.8
	disagree	201	44.8

HCWs' acceptance regarding COVID-19 vaccination

For efficacy and acceptance of the vaccine, 309 (68.8%) reported preparedness to receive the vaccine with an efficacy of 90%. However, the acceptance rate dropped significantly among HCWs when offered the vaccine with an efficacy of 70% (177, 39.4%) and even lower (64, 14.3%) when offered the vaccine with an efficacy of 50%. However, most of the HCWs (277, 61.7%) reported they would encourage their parents to take the vaccine. most of the HCWs would refuse to take the vaccine if it needed to be administered annually (290, 64.6%) and majority of the HCWs would prefer to build their immunity by being infected with COVID-19 rather than taking the vaccine (302, 67.3%). The HCWs’ answers of acceptance questions are demonstrated in Table (9).

Table 9

COVID-19 vaccination acceptance questions (n = 449)
Question	Answer	Frequency	Percent
if COVID-19 vaccine is available with efficacy of 90%, would you be a candidate for receiving the vaccine?	accept	309	68.8
	refuse	140	31.2
if COVID-19 vaccine is available with efficacy of 70%, would you be a candidate for receiving the vaccine?	accept	177	39.4
	refuse	272	60.6
if COVID-19 vaccine is available with efficacy of 50%, would you be a candidate for receiving the vaccine?	accept	64	14.3
	refuse	385	85.7
if COVID-19 vaccine is available with the desired efficacy, would you agree to encourage your parents to get the vaccine?	accept	277	61.7
	refuse	172	38.3
If COVID-19 vaccination would need to be administered annually, would you agree to receive it?	accept	159	35.4
	refuse	290	64.6
will you prefer to build up your immunity against COVID-19 throughout the vaccination or naturally (by being infected with the disease)?	through vaccination	147	32.7
	natural	302	67.3

Association between HCWs' demographic characteristics and knowledge regarding COVID-19 vaccine

A chi-square test was used to assess the association between demographic characteristics and knowledge of COVID-19 and its vaccine, as shown in table (10), HCWs' gender, job, educational level, vaccination status, whether they were dealing with COVID-19 cases or not and their source of COVID-19 related information were statistically associated with level knowledge regarding COVID-19 vaccination (p-value < 0.05) however HCWs' age and whether they were infected with COVID-19 or not show no significant association with the level of their knowledge (p-value ≥ 0.05).

Table 10

Association between HCWs’ knowledge and demographic characteristics
Demographic characteristics		p-value
Participant gender	Male	.009*
Participant gender	Female	.009*
Participants age	20–33 years	.843
	34–47 years
	48–61 years
	61–75 years
Participants job	General practitioner	.005*
	Medical specialist
	Nurse
	Midwife
	Pharmacist
	Laboratory technician
participants educational level	diploma	.001*
	bachelor
	Postgraduate studies
Vaccination state	complete vaccination	.000*
	incomplete vaccination
	not vaccinated
Dealing with suspected or confirmed cases of COVID-19	yes	.012*
Dealing with suspected or confirmed cases of COVID-19	no	.012*
Infected with COVID-19	Yes	.513
Infected with COVID-19	No	.513
What is your main source of COVID-19 related information?	WHO	.000*
	Common rumors in society
	Family and social media
	News and media
	Internet and social media
	Not have special source
p-value is significant at < 0.05*

Association between HCWs' demographic characteristics and attitude regarding COVID-19 vaccine

A chi-square test was used to assess the association between demographic characteristics and attitude regarding COVID-19 vaccine. as shown in table (11), we found that most participants variables are less likely to affect their level of attitude (p-value ≥ 0.05), but a significant association was seen between the HCWs' job, vaccination status and level of education with attitude level (p-value < 0.05).

Table 11

Association of HCWs’ attitude with demographic characteristics
Demographic characteristics		p-value
Participant gender	Male	.373
Participant gender	Female	.373
HCWs age	20–33 years	.363
	34–47 years
	48–61 years
	61–75 years
HCWs job	general practitioner	.015*
	medical specialist
	Nurse
	Midwife
	Pharmacist
	laboratory technician
HCWs educational level	Diploma	.001*
	Bachelor
	postgraduate studies
Vaccination state	complete vaccination	.000*
	incomplete vaccination
	not vaccinated
Dealing with suspected or confirmed cases of COVID-19	Yes	.600
Dealing with suspected or confirmed cases of COVID-19	No	.600
Infected with COVID-19	Yes	.381
Infected with COVID-19	No	.381
What is your main source of COVID-19 related information?	WHO	.301
	Common rumors in society
	Family and social media
	News and media
	Internet and social media
	Not have special source
p-value is significant at < 0.05*

Association between HCWs' demographic characteristics and acceptance of COVID-19 vaccine

A chi-square test was used to assess the association between demographic characteristics and acceptance of COVID-19 vaccine, as shown in table (12), level of acceptance is only affected by the HCWs’ job, vaccination state, whether they were dealing with suspected cases of COVID-19 and their source of COVID-19 related information (p-value < 0.05).

Table 12

Association of HCWs’ COVID-19 acceptance with demographic characteristics
Demographic characteristics		p-value
Participant gender	Male	.314
Participant gender	Female	.314
HCWs age	20–33 years	.921
	34–47 years
	48–61 years
	61–75 years
HCWs job	general practitioner	.000*
	medical specialist
	nurse
	midwife
	pharmacist
	laboratory technician
HCWs educational level	diploma	.314
	bachelor
	postgraduate studies
Vaccination state	complete vaccination	.000*
	incomplete vaccination
	not vaccinated
Dealing with suspected or confirmed cases of COVID-19	yes	.048*
Dealing with suspected or confirmed cases of COVID-19	no	.048*
Infected with COVID-19	Yes	.142
Infected with COVID-19	No	.142
What is your main source of COVID-19 related information?	WHO	.001*
	Common rumors in society
	Family and social media
	News and media
	Internet and social media
	Not have special source
p-value is significant at < 0.05*

Association between HCWs' level of knowledge and attitude with COVID-19 vaccine acceptance

A Pearson correlation coefficient test was performed to determine the association between level of knowledge and attitude with acceptance of COVID-19 vaccine. as shown in table (13), level of acceptance is moderately correlated with attitude level (r = 0.527), however, its weakly correlated with level of knowledge (r = 0.282).

Table 13

Association of HCWs' level of knowledge and attitude with COVID-19 vaccine acceptance.
Items	Knowledge level	Attitude level	Acceptance level
Knowledge level	-	.142	.282
Attitude level	.142	-	.527
Acceptance level	.282	.527	-

Healthcare workers’ influence the behavior of the general population through their own knowledge, attitude and acceptance of COVID-19 vaccine by their consultations. As part of serious efforts to counteract the COVID-19 pandemic, many countries have received various COVID-19 vaccines, including Yemen. As a whole, good knowledge, neutral attitude, and acceptance rates of the COVID-19 vaccines were 65.3% 63.7% and 68.8% (with an efficacy of 90%), respectively.

The use of a self-administered questionnaire instead of online self-reported questionnaires, the various representation among both genders, age groups, healthcare categories and directly dealing with COVID-19 patients represent strengths in this study. The present study provides health officials with detailed insights into the potential barriers affecting COVID-19 vaccination among HCWs.

In the present study, most of HCWs had good level of knowledge (65.3%) about COVID-19 and its vaccine. The results correlate with level of knowledge in Ethiopia (62.5%) but much lower than Kenya (80%) and Uganda (83.9%%), even lower when compared to developed countries as China (89.2%)^{[30,31,32,33]}. There is a correlation between the level of attitude and acceptance to be vaccinated in our study (r = 0.527). HCWs who had a higher level of attitude toward COVID-19 vaccination are more likely to vaccinate. Which agrees with a study in Malaysia where higher knowledge and attitude levels was associated with a higher acceptance regarding vaccination^[34]. However, there was a statistically significant difference in knowledge among both genders, which was not seen when compared to their attitude and acceptance toward the vaccine, indicating that knowledge difference between genders did not affect their attitude and acceptance of COVID-19 vaccine. unlike a study made in France which shows that male HCWs had more knowledge and were more likely to accept the COVID-19 vaccination than female HCWs^[35].

As stated in the results, the HCWs in Mukalla city had good knowledge of COVID-19 and its vaccine. However, we encountered some issues in their understanding. Only half of HCWs (50.8%) were aware that no antibiotic can treat COVID-19, which is parallel to a study made in Malaysia where (49.0%) were aware that the use of antibiotics doesn’t contribute to a faster recovery from COVID-19^[36]. The majority had a gap regarding obstetrical knowledge of COVID-19 vaccine, with only (25.8%) of HCWs being aware of the safety of COVID-19 vaccine during pregnancy and (27.2%) were aware of the safety of lactation during COVID-19 infection, the result is analogous to a study conducted in Libya, which only (18.2%) were aware of the safety of lactation during COVID-19^[37]. Moreover, (36.3%) of HCWs believe that COVID-19 vaccines commonly cause severe side effects. The result agreed with the Libyan study, in which (37%) worry about vaccine complications^[37]. However, this is far from studies made in Saudi Arabia and Ethiopia where (96.5%) of Saudi HCWs and (71.2%) of Ethiopian HCWs were aware of the safety of the vaccine^[38,30]. This low confidence rate of HCWs regrading vaccine efficacy along with fears about adverse effects of the vaccine, which in spite of majority of HCWs being aware of COVID-19 as a serious disease with significant complications (77.7%), it could result in increased hesitancy rate toward the COVID-19 vaccines, significantly impacting community's attitude towards vaccinations. Most of HCWs were aware of the importance of hygiene and self-protection behaviors even after complete vaccination (84.4%), this result also corresponds to a study conducted in India in which (85.9%) were aware of importance of hygiene and self-protection methods regardless of vaccination status^[39]. We also found that less than half of HCWs believe that COVID-19 vaccination prevents the disease complications effectively (47.4%), this was significantly lower than a study conducted Saudi Arabia, where (94%) believed vaccination will reduce complications of COVID-19^[38].

According to a study conducted in Western India, approximately half of HCWs were worried of COVID-19 vaccine (46.0%)^[39]. Another study in Egypt where (45.71%) of HCWs wouldn't advise their patient to receive the vaccine^[40]. These results correlate with our study where (49.2%) of HCWs were worried of COVID-19 vaccination. More than two thirds of HCWs believe that natural immunity can outlast COVID-19 vaccination protection (64.8%), the study result is slightly higher when compared with results from the Egyptian and western Indian studies (48.31%) and (39.2%) respectively^[40,39]. Interestingly, (38.3%) believe there are dangerous problems that we haven't yet discover about COVID-19 vaccine and (39.4%) believe that authorities and media are promoting COVID-19 vaccine for reasons not related to community health, indicating that despite the good knowledge of COVID-19 and its vaccine, HCWs still believe in conspiracy theories of COVID-19. However, (63.3%) of HCWs think that people with chronic or severe diseases should be vaccinated, and (56.8%) believe health care providers should be vaccinated. Although the majority would agree about the priority of HCWs or patients with chronic or severe diseases in receiving the vaccine, the results were significantly lower when compared with the northeastern Ethiopian study where (87.0%) of HCWs agree that patients with chronic or severe diseases were a priority and should be vaccinated along with HCWs (70.4%)^[30]. Most of the HCWs in the study believe COVID-19 vaccine should be offered to every one for free (80.8%), yet only (23.4%) would buy the COVID-19 vaccine if it was for available for sale. This significant drop in attitude also correlates with the Libyan study, where (93.1%) agree that believe COVID-19 vaccine should be offered to every one for free, yet only (48.2%) would buy it^[37].

Concerning COVID-19 vaccine acceptance level in the present study, the majority of HCWs would agree to vaccinate against COVID-19 with an efficacy of 90% (68.8%), but only (39.4%) of them would agree to get COVID-19 vaccination with an efficacy of 70%. This drop in acceptance level was not seen in the Libyan study, where (60.6%) of HCWs were eager to get the COVID-19 vaccine with an efficacy of 70% and (79.6%) with an efficacy of 90%^[37]. According to an American study, the majority of respondents (79.8%) had either gotten or were planned to get the COVID-19 vaccination.^[41]. where another Chinese study had acceptance rate of (82.5%)^[42], this shows high-income countries have high acceptance of the vaccine possibly due to higher perception of COVID-19 infection as well as trust in the health officials^[43]. Our acceptance result agreed with a study conducted in Saudi Arabia (64.9%)^[44], in contrast Lebanon and Egypt had lower acceptance rate of (58%), (21%) respectively^[45,40].

According to the presented study, two thirds of HCWs (61.7%) would agree to encourage their parents to get the vaccine. However, the result is considerably lower compared with the Libyan study where (85.9%) of HCWs would agree to encourage their parents to vaccinate^[37]. Moreover, the majority of the HCWs (67.3%) would prefer to build up their immunity against COVID-19 naturally instead of taking the vaccine, where only (29.9%) of HCWs in the western Indian study agreed to the same option^[39]. This shows that vaccine hesitancy is increasing toward COVID-19 vaccine as the majority of HCWs would endanger their lives at the risk of COVID-19 complications instead of taking the vaccine.

As this study shows there is a statistically significant association between coping with suspected cases of COVID-19 and acceptance to take the vaccine (P-value <0.05), this is consistent with a study in Egypt, revealed that directly dealing with COVID-19 patients triples the chance of acceptance ^[40], as in China, the respondents who are more susceptible to COVID-19 infection were likely to get the COVID-19 vaccine^[42]. This suggests that those who have not dealt with COVID-19 patients are less likely to accept it.

In the current study, a statistically significant association was shown between acceptance and the source of information of the respondents as most of them were receiving information related to COVID-19 from the WHO, while in Saudi Arabia, HCWs were more reliable to obtain Information from governmental health officials.^[44] This shows that reliable resources act as a facilitator for vaccine acceptance. Participant gender have not shown a statistically significant association with acceptance rate which is incompatible with the Saudi, Lebanese, American and Egyptian studies^{[44,45,41,40]}. The latter study justified this relation to increase number of physicians who face the frontline so it may lead to increase the rate of acceptance. A statistically Insignificant association is shown also with age and acceptance rate. This finding is similar to the Egyptian study^[40]. Contrary to expectations, being Infected with COVID-19 hasn’t shown any relationship with acceptance level. It may be due to that most of our HCWs are young so they didn’t suffer from any complications or severe symptoms during infection. However, an American study along with studies in Saudi Arabia and Lebanon have shown an opposite finding^[41,44,45].

The present study has some limitations. Firstly, the cross-sectional study design may be incapable of drawing an accurate conclusion and establishing a strong association; hence, further longitudinal studies are required. Secondly, HCWs may have over-reported good attitudes and acceptance due to social desirability bias. Thirdly, the data given by the hospitals regarding the total number of HCWs and their groupings were not accurate, so number variations between collected sample groupings and sample determined for the study are present. However, our findings were consistent with recently published studies from other countries.

Our study demonstrated the knowledge, attitudes, and acceptance towards COVID-19 Vaccination among Health Care Workers in Mukalla city-Yemen. Our findings may inform health authorities and administrators in developing relevant interventions that promote COVID-19 vaccination uptake among healthcare workers in Yemen. According to the results, HCWs have a good level of knowledge and a neutral attitude toward COVID-19 vaccination. However, acceptance rate was scaling down according to vaccine efficacy. Multiple demographic characteristics were found to be significantly associated with COVID-19 vaccine acceptance among HCWs in Mukalla city and HCWs attitude level positively correlate with higher acceptance regarding COVID-19 vaccine. Moreover, our study revealed that the majority haven't received the complete vaccination course. And multiple misconceptions regarding COVID-19 vaccinate were present. Therefore, authorities have to increase the facilities and encouragements for vaccination, build up the trust and awareness and stand against the conspiracy theories especially for HCWs as they can reflect their thoughts to the general population.

All methods were carried out in accordance with relevant guidelines and regulations.

Acknowledgments

First, we would like to sincerely thank Dr. Mohammed Al-Sakkaf, Dr. Sahar Salem Alammari and Prof. Abdulla Salem Bin-Ghouth for their guidance and contribution.

We would like to thank Abdullah Atash, Mohammad Alsakkaf, Mahfoodh Ben wabar, doaa bin lashram, Mohsen Bin sarea, Ali Albaity for their help in data collection.

Authors' contributions

Background: Aseel Bnqadeem, Khulod Bokir, Aseel Bin Shamlan, Marwan Bahamran, Khawla Dahdah, Somaia Atash. Methodology: Aseel Bnqadeem, Mohammed Alsabban. Ibrahim Aljaberi. Fatima Al-Amodi. Data analysis and results: Mohammed Alsabban, Aseel Bnqadeem, Sumaia Balfaqih, Fatima Bin Marei. Discussion: Aseel Bnqadeem, Khulod Bokir, Roqaia Hussein Alghazali. Sarah Bin Ali Gaber. all authors collected the data for analysis. all authors reviewed the manuscript.

Funding

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

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Ethics approval and consent to participate

An ethical approval of the project was obtained from Hadhramout University College of Medicine, department of Community Medicine. All participants provided informed consents prior to participation.

Consent for publication

Not required

Competing interests

The authors declare that they have no competing interests.

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No competing interests reported.

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Knowledge, Attitudes and Acceptance towards COVID-19 Vaccination among Health Care Workers in Mukalla city-YEMEN: an analytical cross-sectional study

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