Annual COVID-19 Booster Vaccine Acceptance among Healthcare workers: the role of Anti-Vaccination Attitudes and Burnout

Background: The emergence of several SARS-CoV-2 variants may necessitate an annual COVID-19 booster vaccine. This study aimed to evaluate healthcare workers' (HCWs) acceptance of a COVID-19 yearly booster vaccine, if recommended, and its association with their attitudes and burnout levels. Methods: We used an online self-administered questionnaire to conduct a cross-sectional study of all HCWs in the West Bank and Gaza Strip of Palestine between August and September 2022. We used the Vaccination Attitudes Examination scale to assess HCWs' vaccination attitudes and the Maslach Burnout Inventory to assess work-related Burnout. In addition, we conducted logistic regression to identify factors independently associated with the acceptance of the booster vaccine. Results: The study included 919 HCWs; 52.3% were male, 46.5% were physicians, 30.0% were nurses, and 63.1% worked in hospitals. One-third of HCWs (95% CI: 30.5%-36.7%) said they would accept an annual COVID-19 booster vaccine if recommended. HCWs who are suspicious of vaccine bene�ts [aOR= .70; 95%CI: .65-.75] and those concerned about unforeseeable future effects [aOR= .90; 95%CI: .84-.95] are less likely to accept the booster vaccine if recommended, whereas those who receive annual in�uenza vaccine are more likely to get it [aOR= 2.9; 95%CI: 1.7-5.0]. Conclusion: We found that only about a third of HCWs would agree to receive an annual COVID-19 booster vaccine if it was recommended. Mistrust of the vaccine's e�cacy and concerns about side effects continue to drive COVID-19 vaccine reluctance. Health o�cials need to address HCWs' concerns to increase their acceptance of the annual vaccine if it is to be recommended.


Introduction
COVID-19 rst appeared in Wuhan, China, in December 2019 and rapidly spread worldwide, prompting the World Health Organization (WHO) to declare it a pandemic in March 2020.As of September 2022, it is estimated that 610 million people have contracted the disease, with 1.5 million fatalities [1].In Palestine, approximately 620,000 cases have been con rmed, resulting in 5,403 deaths over the same period [2].It also signi cantly impacted the healthcare system, increasing admissions and infection of healthcare workers (HCWs) and decreasing essential healthcare utilization [3].
Vaccination is among the most advantageous health interventions due to its positive effects on population health and the economy.COVID-19 vaccination has effectively prevented the disease and lowered the risk of hospitalization and death [4].This protection, however, declines over time due to waning immunity and, most importantly, the emergence of new virus variants [5].Several SARS-CoV-2 variants have emerged since the pandemic's beginning, the most signi cant of which were Alpha, Beta, Gamma, Delta, and Omicron.These variants were linked to increased transmissibility or virulence and decreased vaccination effectiveness and were responsible for multiple waves of infections worldwide [6].The World Health Organization mentions these to explain why we may need COVID-19 booster doses [7] and raises the possibility that a COVID-19 booster vaccine is required.Some wealthy countries are taking steps in this direction by promoting annual COVID-19 vaccination.According to the White House, the United States could have a COVID-19 booster schedule similar to the annual in uenza vaccine [8].In addition, yearly COVID-19 vaccination is expected in the United Kingdom, particularly for healthcare professionals, to protect against anticipated COVID-19 surges during the winter [9].
The vaccination practices and attitudes of HCWs are central to primary prevention strategies.HCWs who maintain a positive attitude towards vaccination and get vaccinated not only protect themselves, their families, and their patients but may also in uence others, encouraging them to take the vaccine.They are essential as vaccine enablers and communicators to patients and the general public [10].The reluctance of HCWs to accept COVID-19 booster doses may undermine public trust in the vaccine [11].Several studies have shown that HCW vaccination hesitancy is variable.A rapid systematic review found that vaccine acceptance varied widely, ranging from 27.7% to 77.3% [12].Another meta-analysis study revealed that HCWs' COVID-19 vaccine acceptance pooled effect value was 51% [13], while it was generally low in Africa [14].Similarly, studies conducted in Palestine shortly before the vaccine's initial launch showed that HCWs were hesitant to accept the vaccination [15,16].
Hesitancy has been linked to various factors, including sex, profession, education, previous in uenza vaccination, self-perceived risk, concerns about vaccine safety and effectiveness, and many other factors [12][13][14].A recently published study reported that almost a quarter of British HCWs were hesitant to receive a regular COVID-19 vaccination.Age, ethnicity, previous COVID-19 vaccination, attitudes, and in uenza vaccinations in previous seasons were all associated with regular COVID-19 vaccination [17].
Negative attitudes toward healthy behaviors may result from the stress of HCWs [18].Burnout, a psychological work-related stress syndrome that develops in response to occupational stressors [19], is common among HCWs, exacerbated by the COVID-19 pandemic [20].According to Maslach and colleagues, it consists of three elements: emotional exhaustion (EE), depersonalization (DP) (becoming emotionally distant or indifferent), and a diminished sense of personal accomplishment (PA) [19].Burnout has many consequences, including decreased job satisfaction, absenteeism, anxiety, depression, substance abuse, suboptimal patient care, and impaired quality of care [21].
Palestinian HCWs experience high levels of Burnout, which can be attributed to the pressures of daily work and the challenges Palestine faces as a developing country still under occupation [22,23].Besides its direct effects, Burnout may indirectly affect HCWs by lowering service quality regarding adherence to guidelines, poor communication, patient outcomes, and safety [24].
To the best of our knowledge, this is the rst study in the Eastern Mediterranean Region to examine HCWs' willingness to accept and attitudes toward an annual COVID-19 booster vaccine.A better understanding of the acceptance rate of an annual COVID-19 booster vaccine among HCWs and the factors in uencing it would aid in developing interventions to reduce hesitancy and increase uptake.Therefore, this study aims to determine the percentage of Palestinian HCWs who would accept an annual COVID-19 booster vaccine if recommended, as well as the relationship between acceptance, attitude toward the vaccine, and level of Burnout.

Study design and population
Using an online self-administered questionnaire, we conducted a cross-sectional study in all West Bank and Gaza Strip districts between August and September 2022.We targeted Palestinian physicians, nurses, and allied health professionals (lab technicians, radiology technicians, and occupational and physiotherapists) working in hospitals and primary health care centers, both government and non-government.A minimum sample size of 911 HCWs was necessary to determine the prevalence of hesitancy for annual COVID-19 vaccination.It was calculated using the formula n =[DEFF*Np(1-p)]/[(d2/Z21-α/2*(N-1)+p*(1-p), where Z = 1.96 is the con dence level statistic, DEFF = 1 is design effect, P = 33% is the estimated proportion of HCWs willing to receive an annual COVID-19 booster vaccine based on previous studies [15], and d =3% is the absolute precision.Thus, a minimum sample size of 911 HCWs was necessary to achieve the study objectives .
We recruited participants using a convenience sampling strategy, sending out Google Forms links and introductory invitations to closed institutional groups of HCWs (WhatsApp and Messenger).The study was carried out in compliance with current laws on ethical standards and privacy protection.Along with the questionnaire, we enclosed an introductory note explaining the study's purpose and assured respondents that their anonymity and the con dentiality of their responses would be strictly protected.In addition, participants were asked to con rm their agreement with the information provided and their willingness to participate online by tapping the "I agree" item.The Institutional Review Board of An-Najah National University approved the study [Ref.#: Med.August 2022/26].

Measurement tools
The research team created this questionnaire using related literature and previous studies.Before being nalized and distributed to participants, the questionnaire was reviewed by three experts in the eld and piloted with 30 HCWs.It is divided into four sections.The rst section assessed HCWs' background, professional, and clinical characteristics, which included age, gender, profession, workplace place, marital status, smoking status, and presence of chronic diseases.The second section evaluated variables associated with COVID-19 in terms of the history of COVID-19 by polymerase chain reaction (PCR), history of vaccination, and vaccine side effects.Furthermore, we assessed the annual in uenza vaccine uptake by asking, "Do you get the in uenza vaccine every year?".
The third section used the Vaccination Attitudes Examination Scale (VAX) adjusted to the COVID-19 vaccine to assess the HCWs' vaccination attitudes [25].It has 12 items divided into four sub-scales: mistrust of vaccine bene ts, worries over future effects, concerns about commercial pro ts, and preference for natural immunity.Each subscale has three items scored from 1 (strongly agree) to 6 (strongly disagree), except items of the rst subscale, which are reversely coded.Higher scores indicate anti-vaccination attitudes.We used the Arabic version of the VAX scale, which has been used in previous studies and had a high degree of internal consistency [26].The internal consistency coe cient (Cronbach's α) of the VAX scale used in this study was 0.84.
The last section evaluated HCWs' work-related Burnout using the Maslach Burnout Inventory (MBI) [27].It is a 22-item tool that asks participants, on a 7-point Likert scale (from 0, 'never,' to 6, 'daily'), how frequently they had recently experienced speci c feelings related to their work.The MBI is the most commonly used tool, and it consists of three scales: EE (nine items), which measures one's emotional and physical exhaustion as a result of his work; DP ( ve items), which assesses work-related stress, lack of feeling, impersonal responses to patient care, and reduced empathy; and PA (eight items), which evaluates the individuals' perception of their work and re ects how they perceive its signi cance.High scores on the EE or DP scales, or low scores on the PA scale, indicate a high level of Burnout.While no de nite cut-off points for MBI subscales exist, we used the following cut-off points from a previous study on HCWs in the region [28]: Burnout was high on EE and PA, and DP when the scores were ≥35, ≤29, or ≥11, respectively.It was moderate on EE, PA, and DP when scores were 21-30, 41-36, and 6-10, respectively.HCWs who ranked high in all three dimensions were considered to have very high Burnout.Internal consistency (Cronbach's) values for the EE, DP, and PA dimensions used in this study were all high: 0.88, 0.80, and 0.90, respectively.

Study outcome
The questionnaire included a direct question assessing the study's primary outcome by asking HCWs whether they would agree to receive an annual COVID-19 booster vaccine if it is recommended.Respondents were classi ed as acceptant or hesitant based on their responses to the question.Acceptant are HCWs who said "yes," whereas hesitant are those who said "no" or "not decided yet."

Data Analysis
Data entry and analysis were done with the IBM SPSS Statistics for Windows, version 21 (IBM Corp., Armonk, NY, USA).Because we had a large enough sample size (n=919).We summarized categorical variables using frequency distributions and proportions, and the associations were tested using the chi-square test.Next, the Kolmogorov-Smirnov test was used to determine the normality of continuous variables, which revealed that they were normally distributed.The data was then summarized using mean and standard deviation (SD), and the association between different groups was conducted using the independent t-test.The binary logistic regression model was used to account for confounders and assess factors independently associated with vaccine booster dose hesitancy.Adjusted odds ratios (aOR) and 95% con dence intervals (CI) were used to present the ndings.The signi cance level was set at a P-value of less than 0.05.

Background characteristics
The study included 919 HCWs in total.Table 1 shows the sociodemographic and work-related characteristics of the study sample.It was found that 52.3% of respondents were male, 58.8% were under 30, and 53.6% were married.Almost half of the participants were employed by the government, 46.5% were physicians, 30.0%were nurses, and 63.1% worked in hospitals.
According to bivariate analysis, Male HCWs, Physicians, and HCWs working in hospitals were more likely to accept an annual COVID-19 booster vaccine (Table 1) and HCWs who received the COVID-19 vaccine and those who received an annual in uenza vaccine (Table 2).On the other hand, HCWs who are suspicious of vaccine bene ts and concerned about unforeseeable future consequences are more likely to be hesitant (Table 2).PE.In addition, higher levels of vaccine hesitancy were observed among HCWs with moderate and high levels of Burnout in the three domains, but none reached statistical signi cance (Table 3).

Discussion
This study's ndings showed that most HCWs are hesitant about receiving an annual COVID-19 booster vaccine if it is recommended.Only one-third of HCWs would accept it, which is a small number, especially considering the importance of HCWs in society.These ndings are signi cantly lower than those reported among HCWs in high-income countries.For example, in recent surveys, 76.5% of British HCWs [17] and 74.5% of Polish HCWs were willing to receive COVID-19 vaccine booster doses.Higher rates of COVID-19 vaccine booster dose acceptance were reported among HCWs in the United States (83.6%) [29] and China (90.3%) [30].
The COVID-19 vaccine acceptance rate was generally low in low and middle-income countries.According to a recent systematic review and meta-analysis study, the acceptance rate varies across countries, ranging from 20% to 97.8%, with countries in the region such as Egypt, Palestine, Jordan, and Oman having the lowest acceptance rate [31].If the low acceptance rate persists, it may have a negative impact on disease control efforts and the acceptance of by other in uential groups in society, should vaccinations be required.
The effectiveness of vaccines, particularly the booster vaccine, was a major factor in the general public's acceptance of the COVID-19 booster vaccine among Algerians and Americans [32,33].However, employee organization trust plays a signi cant role in hesitancy in the UK.It has also been reported that ethnic diversity affects the hesitancy levels of HCWs [17].In Palestine, and with comparable results in Africa, hesitance to receive a booster vaccination was strongly correlated with a lack of con dence in the value of vaccination [34].Worries about unforeseen future effects were another factor that hindered COVID-19 booster vaccination acceptance.Also, from Poland and Jordan, study participants disagreed that a booster dose of the COVID-19 vaccine would be as safe as the initial doses [35,36].Reassuring HCWs of the e cacy of COVID-19 vaccines and being transparent about their side effects are crucial strategies for addressing vaccine bene ts and fear of side effects, thereby increasing acceptance of booster vaccination.The publication of new studies showing the vaccine's long-term safety can dispel many HCWs' concerns and increase the vaccine's acceptance.
Acceptance of an annual COVID-19 booster vaccine is signi cantly associated with annual in uenza vaccination.A review of COVID-19 vaccination hesitancy among HCWs found that previous vaccination habits, particularly for in uenza, were associated with support for COVID-19 vaccination [37].As participation in healthy behavior is expected to be generic, it is assumed that receipt of a previous COVID-19 vaccine should associate with acceptance of an annual vaccine [29].A systematic review has shown that the use of psychological theories of behavior change (e.g., the health belief model) are promising tools to explain how an individual's likelihood of engaging in protective behaviors depends on their belief about health threat (perceived susceptibility and severity of the disease) and the net bene ts (perceived barriers and bene ts) of engaging in the protective behaviors [38].Our bivariate analysis showed that HCWs who previously had the vaccine were more likely to accept annual boosters.However, the multivariate analysis failed to detect a statistically signi cant relationship between the two variables.This could be either that this relationship is confounded by another variable in the multivariable model, or, more likely, that they are conditioning on a mediating factor such as the score indicating trust in vaccines and thus ablating the association observed on bivariable analysis.
Our results showed no association between gender and willingness to get the annual COVID-19 booster vaccine, contrary to previous studies.Women have historically been more reluctant to receive vaccinations than men [39], speci cally for the COVID-19 vaccine, people surveyed believed that the vaccine could cause infertility [40].Previous COVID-19 intention and uptake studies demonstrated that female HCWs were less likely to intend to take and certainly take the COVID-19 vaccine [15,26].The disappearance of the gender gap for the annual booster COVID-19 in this study could be attributed to the general low acceptance rate among all, as well as the high level of concern about unanticipated future effects shared by both genders.These results emphasize that interventions aimed at increasing uptake of a booster vaccination amongst Palestinian HCWs should not necessarily be targeted toward either gender.
We did not nd a signi cant association between HCW profession and acceptance of an annual COVID-19 booster.French nurses were more reluctant to accept the COVID-19 vaccine during the initial pandemic wave than physicians [41].Similarly, a systematic review study investigated the predictors of vaccine hesitancy and acceptance across different groups reached an identical conclusion [42].Although our analysis did not uncover this correlation, the rate of vaccination acceptance among nurses remains low, which may negatively impact the vaccination compliance of individuals who interact professionally or personally with vaccine-hesitant nurses in the future.
Even though EE was present in one-third of the sample and high DP and low PA were present in approximately half of the sample, these factors were not signi cantly associated with acceptance of annual COVID-19 booster vaccination.A survey conducted in the United States also revealed that stress has no effect on COVID-19 vaccine hesitancy [43].Bivariate analysis revealed that those who reported higher burnout levels for the three subscales were more likely to be hesitant to receive an annual booster, though this was not statistically signi cant.Our results on the prevalence of burnout are signi cantly higher than oncology department workers in Turkey [44], but lower than emergency department workers in Lebanon and Palestine [22,45], given that our sample consists of hospitals, PHC, and private workers.
Our ndings should be interpreted with the following limitations in mind.First, the obtained results may be of limited representativeness due to the non-random sampling technique used to recruit participants for this study.Second, our study is susceptible to self-reporting bias because we asked HCWs to describe their attitude and practices about the COVID-19 vaccines, which could not be entirely correct because they want to make a good impression.Comparing these results to future vaccine uptake would be a useful analysis.Third, even though the rst question in the survey asked HCWs if they agreed to participate, an online survey makes estimating the response rate di cult.This may introduce non-response bias, undermining the study's generalizability.Last, the cross-sectional survey design limits our ability to establish causal relationships, and HCWs' attitudes may change over time.Despite these limitations, the study included a large sample of healthcare workers from various sectors, making it one of the rst to address this issue in this population group.As a result, the ndings should aid in a better understanding of the problem and future research.

Conclusion
In conclusion, the acceptance of an annual COVID-19 booster vaccine is low among Palestinian HCWs.Mistrust of the annual COVID-19 booster vaccine e cacy and concerns about unforeseen side effects remain signi cant factors in COVID-19 vaccine hesitancy.This highlights the importance of health authorities addressing HCWs' concerns in order to increase their acceptance of the annual booster vaccine, if it is to be recommended, which is expected due to the recurrent emergence of different virulent strains in the previous two years, as has been the case for decades with the annual in uenza vaccine.

Supplementary Files
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Figures
Figures

Figure 1 Healthcare
Figure 1

Table 1 :
Participants' background and demographic characteristics with the willingness to get an annual COVID booster vaccine (n=919) *Chi-squared test, † chronic diseases include hypertension, diabetes, cancer, chronic kidney disease, chronic respiratory diseases, and others, • Include private clinics, laboratories, pharmacies, ..etc.

Table 3 :
Burnout among HCWs and its association with the willingness to get an annual COVID-19 booster vaccine

Table 4 :
Multivariable analysis of variables associated with willingness to get an annual COVID booster vaccine (.84-.95) †Reference group, OR= Odds Ratio, CI= con dence interval