Attitudes of vaccination workers toward COVID-19 vaccination in patients with chronic liver disease

doi:10.21203/rs.3.rs-3140629/v1

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Attitudes of vaccination workers toward COVID-19 vaccination in patients with chronic liver disease

https://doi.org/10.21203/rs.3.rs-3140629/v1

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Objectives

Vaccination workers play an important role in the acceptance of various vaccines in patients with chronic liver diseases. We mainly investigated the attitude of vaccination workers toward COVID-19 vaccination in patients with chronic liver disease.

Methods

An anonymous, population-based, cross-sectional online survey were completed by 721 out of 1008 (71.5%) vaccination workers from July 1st to July 14th, 2022, in patients with chronic liver disease in Taizhou, China. The data were uploaded to Wen-Juan-Xing, one of the largest online platforms for collecting survey data.

Results

We found that only 51.9% of vaccination workers recommended all chronic liver diseases vaccinations. 81% of vaccination workers fully recommended vaccination in patients with fatty liver and chronic hepatitis B, while 53.1% of them fully recommended in patients with cirrhosis and liver cancer. Logistic regression analysis showed that vaccination workers who had undergone systematic training were more likely to recommend that patients with four chronic liver diseases get vaccinated (OR: 1.59; 95% CI: 1.05–2.43, p = 0.030). Vaccination workers that believed it is safe to vaccinate against patients with four chronic liver diseases were likely to recommend (OR: 8.12; 95% CI: 1.84–35.88, p = 0.006).

Conclusion

Vaccination workers who hold a positive attitude towards recommending vaccination for patients with chronic liver disease needs to be improved. Strengthening the training of vaccination workers could improve vaccine immunization coverage.

chronic liver disease

COVID-19 vaccine

vaccination workers

clinical recommendations

In the past 3 years, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been a most serious global public health problem. Patients with chronic diseases such as chronic liver diseases (CLD) are more susceptible to SARS-CoV-2 infection and lead to an increased risk of disease progression and mortality(1, 2). COVID-19 vaccination is one of the effective interventions to reduce the infection rate, hospitalization rate, severe infection proportion(3, 4). Although all guidelines recommend COVID-19 vaccination for people with chronic liver disease to provide immunological protection other than acute infection(5–7), many of them will hesitate or even refuse due to various factors included complacency to combat with COVID-19, perception of vaccine safety and efficacy, the ability of government's response to pandemic, and etc.(8, 9).

Vaccination workers refer to systematic vaccination trained health workers who work in community medical institutions or departments of disease prevention and control(10). In addition to vaccination, they are primary health information providers and play an important role in the acceptance of various vaccines by the general population (11, 12). At present, few studies have focused on the role of vaccination workers and concerned about their attitudes towards vaccination in patients with chronic liver disease. Exploring the attitudes and knowledge of vaccination workers towards vaccination can help to better evaluate their impact on vaccination rates.

2.1. Study design and data collection.

This study conducted an anonymous, population-based, cross-sectional online survey. Data were collected through the Wen-Juan-Xing platform from July 1st to July 14th, 2022, which is the largest online questionnaire platform in mainland China. Vaccination workers who were employed at vaccination service centers in Taizhou were enrolled. The inclusion criteria were as follows: (1) working currently as vaccination workers; (2) voluntary participation in this survey. Participants’ personal information was fully anonymized, such as name, email and telephone number. The Unified Resource Locator (URL) link and Quick Response (QR) codes generated by Wen-Juan-Xing Platform are shared for the survey. A total of 1,008 participants received the questionnaire and 721 valid samples were included with a response rate of 71.5%.

This manuscript was approved by the Ethics Committee of the Taizhou Hospital of Zhejiang Province (approval number: K20210705). The study was performed in accordance with the ethical guidelines of the World Medical Associated (Declaration of Helsinki) and the CHERRIES statement.

2.2 Structured questionnaires and measurement

We constructed an online structured questionnaire based on previous studies and relevant background information. The formal questionnaire was developed by a panel of two experts in the relevant field to ensure that the content was comprehensive, valid, and scientific. We piloted the initial questionnaire with 20 adults and then utilized the testers' feedback to revise the questionnaire into its final version. The structured questionnaire was developed in Chinese, which included as follows:

(1) General demographic information (including gender, age, education, Seniority, and professional qualifications.)

(2) Background information on the vaccination of patients with chronic diseases and cancer contained two questions: “Are you aware of the guidance relating to COVID-19 vaccination for people with chronic diseases and cancer?” “Have you received systematic training on COVID-19 vaccination for patients with chronic diseases and cancer?”

(3) Perceptions of COVID-19 vaccine safety: “What do you think about the safety of the COVID-19 vaccine for patients with chronic diseases and cancer?”

(4) Concerns about COVID-19 vaccination for chronic disease patients, evaluated using the question: “Do you have any concerns about getting the COVID-19 vaccine for patients with chronic diseases and cancer?”

For simplicity, vaccination workers’ recommendations toward vaccination for the four chronic liver diseases were re-recorded in the final analysis, with “Not recommended” and “Partial recommendations” re-recorded as "Not all recommended”.

2.3 Statistical analysis

Data were analyzed using the IBM SPSS Statistics software (version 26.0; SPSS Inc., Chicago, IL, USA). Statistical significance was determined at p < 0.05. Categorical variables were presented as frequency and percentage. Chi-square tests were used to evaluate the differences in the demographic and personal background variables of the vaccination workers who were all recommended and not all recommended to receive COVID-19 vaccine for patients with chronic liver diseases. variables with p < 0.05 in the univariate analysis were included in binary logistic regression model. Logistic regression, with a odds ratio (OR) and 95% confidence interval (CI), was used to identify the factors influencing vaccination workers recommendations on COVID-19 vaccination for patients with the four chronic liver diseases.

A total of 721 participants completed the questionnaire during July 1 to Jury 14, 2022. As shown in Fig. 1, 51.9% of vaccination workers did recommend four chronic liver disease to get vaccinated. Vaccination was recommended by 91.5% of vaccination workers for patients with fatty liver, followed by patients with chronic hepatitis B (81.3%) and cirrhosis (65.3%). Vaccination for patients with liver cancer was recommended by only 53.8% of the vaccination workers.

To further explore the attitudes of vaccination workers towards different chronic liver diseases, we divided the four liver diseases into two types (fatty liver and chronic hepatitis B, cirrhosis and liver cancer). Among the patients with fatty liver and chronic hepatitis B, 81% of the inoculation workers fully recommended vaccination, but only 53.1% of the inoculation workers fully recommended vaccination for patients with cirrhosis and liver cancer (Fig. 2).

Table 1 showed the characteristics of the participants. 80.9% were females, 60% were aged < 40 years, 64.5% had undergraduate and above education, 63.2% were the Seniority for more than 10 years, 10.1% had the medium grade of professional qualifications. 77.9% of vaccination workers who recommended for COVID-19 vaccine had received systematic training. Table 1 summarized the attitude of vaccination workers to receive vaccine for patients with four chronic liver diseases. Education, seniority and professional qualifications did not differ significantly between vaccination workers with all recommendations and without all recommendations to vaccinate patients with chronic liver diseases (p > 0.05). For the gender (χ² = 7.460, p = 0.006) and age (χ² = 8.353, p = 0.015) of vaccination workers, the difference was statistically significant. We found that vaccination workers' knowledge of chronic diseases vaccination guidelines (χ² = 10.774, p = 0.001) and experience with systematic training (χ² = 20.978, p < 0.001) had a significant impact on their recommendation to accept vaccine for patients. From the overall perception of vaccination workers, they had a high degree of trust in the safety of chronic diseases vaccination (χ² = 42.978, p < 0.001) and less apprehension about COVID-19 vaccination in patients with chronic diseases (χ² = 103.786, p < 0.001). Logistic regression analysis showed that after adjust for education, seniority and professional qualifications. The following demographic factors were shown the significant findings. Men were more positive about vaccination for patients with chronic liver diseases than women (OR: 1.62; 95% CI: 1.06–2.47, p = 0.025). Vaccination workers who had undergone systematic training were more likely to recommend that patients with four chronic liver diseases get vaccinated (OR: 1.59; 95% CI: 1.05 2.43, p = 0.030). Vaccination workers that believed it is safe to vaccinate against patients with four chronic liver diseases were likely to recommend (OR: 8.12; 95% CI: 1.84–35.88, p = 0.006). Vaccination workers who are not concerned about adverse reactions to vaccination in patients with chronic liver disease (OR: 0.25; 95% CI: 0.18–0.35, p < 0.001) were more likely to recommend.

Table 1

Univariate analysis of factors associated with vaccination workers’ attitude to chronic liver diseases (n = 721)
Variables	Categories	Total n(%)	Vaccination workers (n = 721)		χ2	P-value
			Not all recommended	All recommended
			(n = 347)	(n = 374)
Gender	Male	138 (19.1)	52 (15.0)	86 (23.0)	7.460	0.006
	Female	583 (80.9)	295 (85.0)	288 (77.0)
Age (years)	< 40	433(60.1)	196(56.5)	237(63.4)	3.577	0.059
	≥ 40	288(39.9)	151(43.5)	137(36.6)
education	Junior college and below	256(35.5)	131(37.8)	125(33.4)	1.474	0.225
	Undergraduate and above	465(64.5)	216(62.2)	249(66.6)
Seniority	1 ~ 4	116(16.1%)	226(65.1)	230 (61.5)	1.259	0.533
	5 ~ 9	149(20.7%)	70(20.2)	79 (21.1)
	≥ 10	456(63.2%)	51 (14.7)	65 (17.4)
professional qualifications	Primary grade	348(48.3%)	165 (47.6)	183 (48.9)	0.147	0.929
	Medium grade	300(41.6%)	146 (42.1)	154 (41.2)
	Senior grade	73(10.1%)	36 (10.4)	37 (9.9)
Are you aware of the guidance relating to COVID-19 vaccination for patients with chronic diseases?
	Yes	668(92.6%)	310 (89.3)	358 (95.7)	10.774	0.001
	No	53(7.4%)	37 (10.7)	16 (4.3)
Have you received systematic training on COVID-19 vaccination for patients with chronic diseases?
	Yes	562(77.9)	245 (70.6)	317 (84.8)	20.978	< 0.001
	No	159 (22.1)	102 (29.4)	57 (15.2)
What do you think about the safety of the COVID-19 vaccine for patients with chronic diseases?
	High	656(90.0%)	291 (83.9)	365 (97.6)	42.146	< 0.001
	Uncertainty	38(5.3%)	31 (8.9)	7 (1.9)
	Low	27(3.7%)	25 (7.2)	2 (0.5)
Do you have any worries about getting the COVID-19 vaccine for patients with chronic diseases?
	Yes	356 (49.4)	103 (29.7)	253 (67.6)	103.786	< 0.001
	No	365 (50.6)	244 (70.3)	121 (32.4)
Note: n (%), count (percentage).

Table 2

Independent factors related to vaccination workers’ attitude for chronic liver diseases by binary logistic regression model (n = 721)
Variables	Categories	Vaccination workers (n = 721)
Variables	Categories	P-value	OR(95%CI)
Gender	male vs. female	0.025	1.62 (1.06–2.47)
Are you aware of the guidance relating to COVID-19 vaccination for patients with chronic diseases?
	yes vs. no	0.949	1.02 (0.51–2.07)
Have you received systematic training on COVID-19 vaccination for patients with chronic diseases?
	yes vs. no	0.030	1.59 (1.05–2.43)
What do you think about the safety of the COVID-19 vaccine for patients with chronic diseases?
	high vs. low	0.006	8.12 (1.84–35.88)
	uncertainty vs. low	0.197	3.03 (0.56–16.35)
Do you have any worries about getting the COVID-19 vaccine for patients with chronic diseases?
	yes vs. no	< 0.001	0.25 (0.18–0.35)

Our results showed that 77.9% of vaccination workers who recommended for COVID-19 vaccine had received systematic training. It suggested that systematically trained staff are more likely to recommend vaccinations for chronic liver disease. Education and training could improve the vaccine-related knowledge, attitudes and beliefs, prompt vaccination workers to better understand the safety of vaccines, properly handle vaccine-related issues, and achieve effective communication with subjects in future practice(13). In addition, this study indicated that 77.9% vaccination workers had received systematic training, and only 56.4% of these systematically trained staff are fully recommended to be vaccinated against COVID-19, indicating that the existing training effect needs to be improved. Systematic training is defined as the provision of vaccination knowledge and skills for vaccination workers or medical students, which helps vaccination workers to provide the public including policy information and vaccine safety for the purpose of increasing vaccination coverage(14). Some studies had referred to systematic training of vaccination workers on vaccination recommendations and vaccination(10, 12). Systematic training mainly including as follow: (1) common adverse events after vaccination, (2) resources of doctors with experienced in handling adverse reactions, and (3) communication with a vaccine-hesitant population(14). In addition to the usual guideline-related courses, methods such as presumed initiation of vaccines, optimizing conversations through motivational interviewing (PIVOT with MI), case-based learning, and emulation of the “social vaccine” model are worth exploring in future training to improve the coping capacity of vaccination workers(10, 15, 16). Concerns about the safety and efficacy of COVID-19 vaccines were listed as the main reasons for vaccine hesitancy(17). Systematic training effectively solves this problem, and systematically trained vaccination workers can play a better role in promoting vaccines. Sanitary institutions should strengthen the systematic training of vaccination workers in the process of future strategy formulation.

With the emergence of new variants such as Omicron, the efficacy of COVID-19 vaccine is particularly limited. However, it still controls the rise in severe infected cases (18). Vaccination is one of the key steps to control the current pandemic, the number of vaccination workers and positive attitudes in vaccine promotion play an important role in improving immunization coverage(19). During the pandemic, lower vaccination rates are considered a vital factor that is not easy to control. In other words, low vaccination rates are more likely to lead to outbreaks(20). Patients with chronic liver disease are at increased risk of COVID-19 morbidity and mortality, and vaccination should be recommended for all eligible patients(6). Considering the safety of existing vaccines, the COVID-19 vaccine does not need to be delayed or stopped in patients with chronic liver disease(7, 21). In our real-world survey, only 51.9% of vaccination workers had positive recommendations for chronic liver disease. In fatty liver and chronic hepatitis B, 81% of vaccination workers recommended vaccination, while in patients with cirrhosis and liver cancer, the proportion of proactive recommendations (53.1%) has decreased significantly. The attitude of the vaccination workers has not become very positive towards the COVID-19 vaccination of the chronic liver disease. Therefore, they are naturally affected by own point of view during vaccination promotion, and the vaccination coverage has declined. Authoritative Guidelines for Chronic Liver Diseases(5–7)recommend that patients with chronic liver disease should zealously receive COVID19 vaccine, but in the real world, COVID-19 vaccine coverage is greatly affected by the population's trust in government source information, and the vaccine acceptance rate shows significant regional differences globally(22). Factors such as comorbidities, weighing the risks of vaccination against disease, and the curability of COVID-19 still affect people's attitudes towards vaccination(23). In addition to the cognition, acceptance and accessibility of vaccine have affected vaccination uptake(24), our study showed that vaccination workers' attitude towards recommendation of COVID-19 vaccine is an another important factor relating to vaccination coverage.

Gender may be also one of the factors affecting the attitude of vaccination workers towards COVID-19 recommendations. In our study, it can be observed that male vaccination workers have positive attitudes towards vaccination, and the effect of gender on vaccination attitudes has been confirmed in other studies(25–29), which may be related to their perception of conspiracy theories surrounding the disease and vaccines, as well as the severity of COVID-19.

Our study includes some limitations. Firstly, our respondents were recruited from the staff of the Vaccination Service Center in Taizhou, which has geographical restrictions, and the results may be biased. Secondly, women accounted for the majority of the population we investigated, and the results showed that men recommended vaccination more actively. a larger sample size is needed to support the results in future. Thirdly, our questionnaire was evaluated at a single time point. The attitudes of vaccination workers towards vaccine recommendations were influenced by various factors, such as emotion, trend of epidemic evolution, and policy of institutional training, which cannot reflect the overall attitude and cognition of vaccination workers during the continuation of the pandemic.

In our study, the proportion of vaccination workers who hold a positive attitude towards recommending vaccination for patients with chronic liver disease needs to be improved, and their willingness to vaccine recommend in complicated patients is even lower. It affects the immunization coverage of susceptible population. Systematically trained vaccination workers prefer to recommend COIVD-19 vaccination. Consequently, strengthening the training of vaccination workers will help to improve vaccine immunization coverage among patients with chronic liver disease.

Disclosure statement

All authors have no conflict of interest to declare.

Funding Statement

This work was supported by The Science and Technology Project of Taizhou (No. 1901ky14) and Science and Technology Administration Public Interest Technology Research Project of Zhejiang province (No. LGF19H030013).

Ethics approval and consent to participate

This study was exempted from informed consent and approved by the Ethics Committee of Taizhou Hospital of Zhejiang Province, China (Approval number: K20210520).The study procedure was approved by the Ethics Committee of Taizhou Hospital, Zhejiang Province and was performed in accordance with the ethical guidelines of the World Medical Association (Declaration of Helsinki) and the CHERRIES statement.

Availability of data and materials

The data used for this study, although not available in a public repository, will be made available to other researchers upon reasonable request.

Authors' contributions

J.S. Z. and T.H.T. conceived the study and designed the questionnaire. X.Q.L. ,X.H.Y and G.M.X. collected data. C.L.H. and Y.Z.T.was responsible for analyzing and writing the first draft of the paper. C.Q.Y. and J.S.D. searched for, sorted, and interpreted the relevant literature. All authors have edited and approved the final manuscript.

Competing interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in this manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants, or patents received or pending, and royalties.

Acknowledgments

We thank the participants for their cooperation and support.

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No competing interests reported.

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Version 1

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Attitudes of vaccination workers toward COVID-19 vaccination in patients with chronic liver disease

Status:

Version 1

Abstract

Objectives

Methods

Results

Conclusion

Figures

1. Introduction

2. Materials and Methods

2.1. Study design and data collection.

2.2 Structured questionnaires and measurement

2.3 Statistical analysis

3. Results

4. Discussion

5. Conclusion

Declarations

References

Additional Declarations

Status:

Version 1