Willingness for COVID-19 Vaccination and Influencing factors in Nurses from Tangshan City, China: A Cross-sectional Study

Background: To understand the willingness of nurses from Tangshan City to undergo Coronavirus disease 2019 (COVID-19) vaccination and identify its influencing factors. Methods: : In January 2021, 255 nurses from five medical institutions across Tangshan City were investigated through convenience sampling on a network platform of Sojump. Furthermore, SPSS Statistics v24.0 software was used for general descriptive analysis, rank-sum test and binary logistic regression analysis to analyse willingness rates for COVID-19 vaccination and corresponding influencing factors. Results: : A total of 255 valid questionnaires were collected (recovery rate, 85.71%). Among the 255 nurses surveyed, the willingness rate was 67.8%. The major reasons for willingness to undergo COVID-19 vaccination included a high-risk work environment necessitating COVID-19 vaccination (87.9%), expected benefits to themselves and others (72.8%) and worries regarding COVID-19 infection (66.5%). Meanwhile, reasons for unwillingness to undergo COVID-19 vaccination in 82 nurses included concerns regarding safety (89.0%), effectiveness (62.2%) and the possibility of fake vaccines (32.9%). Furthermore, among the 255 nurses, 43.9% were willing to recommend COVID-19 vaccination (n = 112), with the main reasons being prevention of COVID-19 infection (100.0%) and herd immunity via universal vaccination (90.2%). Moreover, the main reasons for unwillingness to recommend COVID-19 vaccination included poor popularity and wait-and-see attitude (85.3%) and hesitancy to recommend given the absence of COVID-19 vaccines (67.1%). With regard to attitude towards COVID-19 vaccine marketing, 149 (58.5%) nurses expressed favour, 101 (39.6%) nurses took a neutral position and 5 (1.9%) expressed displeasure. Univariate analysis revealed that male nurses, as well as those who actively inquired and sought information on COVID-19 vaccines, had significantly higher willingness for vaccination compared to female nurses and those not actively seeking information (P < 0.05). Meanwhile, binary logistic regression analysis indicated that gender, degree of education, working years and active inquiry or search for vaccine information were associated with willingness for COVID-19 vaccination (P < 0.05). Conclusion: This study highlights the need for further improving the willingness of nurses from Tangshan City to undergo and recommend COVID-19 vaccination. Relevant departments should therefore publicise information regarding COVID-19 vaccines for medical staff to ensure the safe and effective promotion thereof.


Background
Since the outbreak of the Coronavirus Disease 2019  in Wuhan, Hubei, China, starting from the end of 2019, the number of COVID-19 cases has rapidly increased [1]. According to the latest COVID-19 time-series data from Johns Hopkins University, over 100 million people worldwide had been infected as of 5 February 2021, of whom >2 million had died [2]. This pandemic has seriously affected various industries, leading to the most severe economic recession in various countries since World War II, along with considerable lifestyle disruptions [3]. In China, effective prevention and control measures have been adopted to ensure maximum safety. However, small-scale outbreaks have still occurred in Hebei, Heilongjiang, Jilin and other parts of China in early 2021. This suggests that COVID-19 still exerts a considerable impact on human health and life and will likely persist for much longer, indicating the criticality of pandemic prevention and control in China and the world [4].
Vaccination is generally the most effective approach in controlling infectious diseases [5]. To effectively prevent and control the pandemic, countries worldwide have devoted themselves to the active development of vaccines against COVID-19. At present, a number of vaccines are in the stage of research and development or marketing. On 11 December 2020, the US Food and Drug Administration approved the emergency use authorisation of the COVID-19 vaccine jointly developed by P zer Inc. and BioNTechthe rst vaccine against COVID-19 put into large-scale use throughout the United States [6]. On 30 January 2021, the Agenzia Italiana del Farmaco approved the utilisation of the AstraZeneca vaccine in all adults [7]. Simultaneously, the development of COVID-19 vaccines in China has also been essentially completed, with over 10 million vaccine doses having been developed since the implementation of vaccination programmes for key populations on 15 December 2020 [8]. Indeed, evidence has shown that COVID-19 vaccination can improve individual immunity to the virus [9], which can effectively control the spread of the COVID-19 pandemic.
The COVID-19 pandemic has certainly placed a considerable burden on the global health care system [10]. Medical workers, especially nurses who most frequently come in contact with patients, are at high risk for COVID-19 infection [11,12]. Health personnel immunisation can be an approach to reduce the spread of pathogens and reduce personnel and labour costs during the pandemic [13]. Therefore, enhancing nurses' immunity against COVID-19 is imperative given its ability to reduce not only the risk of COVID-19 infection but also the operational and labour costs of medical institutions. According to the Strategic Advisory Group of Experts on Immunization, the Tailoring Immunization Program combines health behaviour theory with social determinants and classi es factors in uencing vaccination into four categories, including environment mechanism, social support, personal motivation and health worker factors [14][15]. Given that medical staff has been considered a source of important medical information for the public, medical staff knowledge has a critical impact on public vaccination behaviour. As such, medical staff consultations can be a key factor that in uences whether or not the public decides to vaccinate [16].
To understand the willingness of nurses from Tangshan City of Hebei province to undergo COVID-19 vaccination and factors in uencing the same, nurses from medical institutions across Tangshan City were investigated in January 2021 using convenience sampling on the network platform of Sojump. Our results can be expected to provide an objective reference for relevant departments in Tangshan City to formulate vaccination plans against COVID-19 and promote COVID-19 vaccination.

Study participants
Study participants identi ed using convenience sampling from two third-class hospitals, one secondclass hospital and two rst-class hospitals in Tangshan City, Hebei Province were screened by the researchers. After obtained consent from hospital managers, chief nurses of each hospital selected quali ed nurses to complete the questionnaire using the 'Sojump' network platform. The inclusion criteria were as follows: (1) on-the-job nurses at medical institutions of all levels; (2) those with practice certi cates; (3) those who can act independently and complete the questionnaire using mobile phones and other electronic devices independently; and (4) those who provided informed consent for this study. The exclusion criteria were as follows: (1) interns and nurse trainees and (2) those on leave (e.g. maternity and marriage leave).

Survey tools
General information questionnaire The general information questionnaire is composed of ten items that determine information regarding gender, age, place of residence, degree of education, marital status, monthly income, working years, professional title, work department and hospital level.

Questionnaire on nurses' willingness to undergo COVID-19 vaccination
Questionnaire items were designed preliminarily by the researchers after literature review and group discussion. The consultation form was distributed to ve experts holding a deputy senior position or greater to modify the questionnaire according to the experts' evaluation and opinions. Ultimately, the questionnaire included 27 items that determined willingness and reasons for vaccination, willingness and reasons for recommending vaccination to others, attitude towards vaccine marketing, psychological price of the vaccine and attitude towards the pandemic. Multiple-choice questions regard each option as 1 item, a total of 5 multiple-choice questions. A total of 20 nurses were pre-surveyed before the formal questionnaire was issued. The questionnaire was then adjusted appropriately based on the pre-survey results, while the nal questionnaire was generated after deleting two items during the process.

Data collection
After obtaining the consent from the person in charge of each hospital, the questionnaire link and instructions were sent by the researchers to the Nursing Department and chief nurses of each hospital using the 'Sojump' network platform and Wechat from January 8 to 12, 2021. Thereafter, the Nursing Department and chief nurses sent the link and instructions for the questionnaire to the clinical nurses, who then completed the questionnaire through their mobile phones and other electronic devices. The same device can only be used once to prevent repeated lling, while questionnaires with incomplete data were prevented from being submitted to ensure data integrity. After data collection, questionnaires were veri ed, subsequently excluding those with obvious logical errors. Questionnaires completed by nurses outside of Tangshan City were excluded based on the nurses' IP address upon lling and the current place of residence. Before answering, all respondents were informed regarding the purpose of the survey and had provided signed written informed consent online.

Statistical analysis
Data were loaded through the back-end database of Sojump and sorted by two investigators using Excel 2019. SPSS 24.0 statistical software was used for data analysis. Descriptive statistics were used for classi cation, the rank-sum test was used for univariate analysis and binary logistic regression analysis was used for multivariate analysis. Statistical signi cance was set at a two-tailed α value of 0.05.

Ethical Considerations
The Ethics Committee of North China University of Science and Technology approved this study. The researchers informed all the participants about the objective of the study. All participants signed informed consent forms, and they were informed about the anonymous and con dential nature of their data. The study was conducted following the ethical aspects put forth in the Declaration of Helsinki.

General data
Among the 282 questionnaires collected, 255 were con rmed after excluding invalid questionnaires, resulting in a recovery rate of 90.4%. As shown in Table1, the respondents came from ve hospitals, including two third-class hospitals, one second-class hospital and two rst-class hospitals. Respondents had an average age of 32.11 ± 7.65 years (range, 21 to 59 years).  Table 2 summarises the details regarding reasons for willingness/unwillingness.   Table 4.

Analysis of factors in uencing nurses' willingness for COVID-19 vaccination
Univariate analysis of nurses' willingness for COVID-19 vaccination As described in Table 5, univariate analysis revealed that male nurses and those who actively inquired and sought information regarding COVID-19 vaccines had signi cantly higher willingness for vaccination compared to female nurses and those who did not inquire and seek information (P < 0.05). Accordingly, our results showed that gender, degree of education, working years, initiative to inquire or search for vaccine information were related to the willingness for COVID-19 vaccination (P < 0.05), as presented in Table 7.

Discussion
The highly contagious COVID-19 has currently remained prevalent globally, with droplet and contact transmission being its primary mode of transmission [17]. All countries worldwide have devoted themselves to actively developing vaccines against COVID-19 to curb the pandemic. According to relevant research, vaccination rates against COVID-19 needs to reach at least 47% to achieve herd immunity, with a higher COVID-19 basic reproduction number (R 0 ) possibly requiring higher vaccination rates to achieve herd immunity [18].
By the end of 2019, a total of 212 hospitals of all levels and 23,000 registered nurses were recorded in Tangshan City [19], with the current study selecting a total of 255 nurses from ve hospitals across  [12]. Compared to the aforementioned studies focusing on foreign medical staff, the current found relatively higher willingness for vaccination among medical staff in China. However, nurses included herein still had lower willingness compared to Chinese residents (88.6%), as reported by Lazarus et al. [21]. This could be explained by the considerably greater medical knowledge among medical workers relative to residents. However, most of the vaccines against COVID-19 are still in clinical trials and have gained relatively poor reliability reputation given the public's scepticism regarding the safety and effectiveness of the vaccine. Meanwhile, the effective control of the pandemic situation in China has also reduced the willingness of medical staff to undergo COVID-19 vaccination to a certain extent. However, based on the survey results on vaccination willingness rates obtained herein, a universal vaccination plan against COVID-19 in China would certainly be able to achieve herd immunity.
Nevertheless, providing more information related to COVID-19 vaccines to medical staff is still necessary. and effectiveness (62.2%), which was essentially consistent with the research results presented by Mohaithef and Kreps [22][23]. This can be explained by the following two reasons. Firstly, the COVID-19 pandemic spreads rapidly, accompanied by a high risk for mutations in the novel coronavirus. At present, over 100 subtypes of the novel coronavirus have been recorded, causing public concern over the effectiveness of the vaccine and fear for the absence of preventive effects after vaccination. Secondly, some limitations in medical research are still presented given the relatively recent (i.e. over 1 year) discovery of the novel coronavirus. Therefore, the safety of vaccines against COVID-19 in various countries has been questioned, leading to low vaccination willingness rates among nurses. Moreover, 32.9% of nurses were worried about fake vaccines mainly due to the endless vaccine problems in China over the recent years, which has affected the Chinese public's con dence in the role of vaccines in disease prevention.
Health workers may play an important role in promoting public willingness to undergo vaccination [15], vaccines and promote nurses' awareness so as to improve their willingness to undergo vaccination.

Conclusion
The current study revealed that nurses in Tangshan City had a high degree of acceptance towards COVID-19 vaccination. Nonetheless, there is certainly room to further improve nurses' willingness to undergo and recommend vaccination against COVID-19, with most nurses hoping to avoid COVID-19 infection through vaccination. Moreover, relevant departments are encouraged to implement positive and adequate measures to strengthen nurses' knowledge regarding COVID-19 vaccines to better prepare COVID-19 vaccination programmes. Similarly, strengthening public opinion, emphasising problems relevant to nurses and enhancing nurses' con dence in vaccination are imperative against COVID-19.

Declarations
Ethics approval and consent to participate This study was approved by the Ethics Committee of North China University of Science and Technology.
The purpose of the research was explained to all participants and the con dentiality of the researchers was guaranteed. The survey also included an informed consent form. Fill out this form and then complete the survey, indicating that the participant agrees to the research. The statement in the introductory part of the questionnaire clearly indicates the voluntary nature of participation, and states that anonymity, con dentiality and the fact that the research results are only used for research purposes.