COVID-19 vaccine acceptance, barriers and facilitators among healthcare workers in Pakistan

Background Vaccines are one of the main cornerstones in the global initiatives to control the COVID-19 pandemic. National vaccination programs largely depend on vaccine availability and acceptance by a large proportion of the population to confer a measurable impact on SARS-CoV-2 transmission. In this study we determine the acceptance, barriers and facilitators of COVID-19 vaccination amongst healthcare workers (HCWs) in Pakistan Methods A structured and validated questionnaire was used in an online cross-sectional study. Health care workers residing in Pakistan were invited between 31st January to 9th February to participate in this survey. Results A total of 436 health-care workers took part in this survey and among those 327 (75%) were doctors. 260 (60%) health-care workers indicated that they would accept vaccination against COVID-19. 308 (71%) were completely condent or condent in using USA, UK manufactured COVID-19 vaccine. The acceptance concerning a potential Chinese vaccine was 267 (61%). 292 (67%) strongly agreed or agreed that they are concerned about the ecacy of COVID-19 vaccination while the concerns for safety were 293 (67%). Conclusions About a third of HCWs, a group generally biased towards early acceptance of health interventions – expressed concerns or refusal of vaccination against COVID-19 in this survey. A dedicated communication plan and information campaign addressing the issues of ecacy, quality, logistics and religious concerns is needed to address these hurdles to allow for a successful national vaccination campaign.

Data was collected using self-reported, structured questionnaire adapted from Lin Y et all (12). Data were collected via an online Google forms. The survey was open for response between 31st January to 9th February. The identity of health care personnel validated by their registration number, which was kept con dential.

Data analysis:
Data were extracted from the online Google forms, transferred and analyzed by using STATA Version 14. All the categorical variables (gender, professional role, vaccine acceptance etc) were described as frequencies and percentages. Group-testing was performed using chi square test with p ≤ 0.05 considered signi cance.
Out of 436 respondents, n=133 (31%) had tested COVID-19 positive. Total 68 (16%) respondents have an existing chronic disease such as cardiovascular disease, diabetes and chronic respiratory tract disease. When asked, about if they had adequate information regarding the COVID-19 vaccine, only 202 (46%) of the health-care workers agreed with having adequate information.
Total 292 (67%) strongly agreed or agreed that they are concerned about the e cacy of COVID-19 vaccination whereas 293 (67%) are concerned about the safety of COVID-19 vaccination including 238 (54.5%) voicing concerns about potential fake and faulty COVID-19 vaccine. 320 (73.3%) indicated concerns about the cold chain maintenance of COVID-19 vaccine and 125 (28.6%) about the permissibility of COVID-19 vaccine on religious ground. 128 participants (29.3%,) assumed that there might be hidden motives behind eagerness of authorities to administer / provide COVID-19 vaccine free. Respondent's further details on the respondent's characteristics are provided in Table 02(a-c).
The majority of respondents were from the KPK province of Pakistan. Further details of the KPK respondent's characteristics are provided in Table 03(a-c) A separate analysis was run for total 133 respondents who were COVID-19 positive among which a majority were doctors and working at tertiary care hospitals 67(50%) of Pakistan. 72 (54%) responded that they are willing to take a COVID-19 vaccine if available. 95 (71%) strongly agreed or agreed that they would feel less worried of contracting COVID-19 if vaccinated. 31 (23%) were concerned about permissibility of COVID-19 vaccine on religious grounds. The details given in Table 04.

Discussion
Knowledge, attitude and practices of HCWs is important to understand to guide vaccination programs. Pakistan is a particularly complex region for population based vaccination programs due to a history of vaccine hesitancy in the past. This survey therefore aimed to address proactively the major barriers for vaccine acceptance to help guide information management to effectively accompany the national COVID-19 response.
Importantly, about one third of health care workers in our survey indicated to postpone or refuse taking a COVID-19 vaccine.
Given that these individuals are HCW, disproportionally young and well educated this seems a rather high proportion. This group of respondents is thought to be rather geared towards acceptance of evidence based interventions, which makes the signi cant proportion of hesitant individuals even more important. In similar studies done in health workers of other countries vaccine acceptance has been reported to be within a borad range from 28% in DRC, 40% in Hong Kong, 61% in Israel, 63% Hong Kong, up to 77% in France (6, 13-16). Interestingly, HCWs showed a trend towards more trust in US/UK manufactured vaccines than on a Chinese vaccine. This is important for the Pakistani context as two Chinese vaccines (Sinopharm, CanSino) are planned to be the main vaccines for the national control program. Concerns regarding logistics and quality assurance are justi ed concerns that need to be addressed both on the operation level as well as should be included in information campaigns. Importantly, one third of respondents also indicated issues with religious permissibility as a concern. This particular topic requires further investigation and engagement with religious leaders to potentially overcome this important hurdle in the effective implementation of the national COVID-19 vaccination program.
As mentioned above, this survey is probably not fully representative for the Pakistani population as it signi cantly overrepresents young male HCWs with high education from one part of Pakistan. Nevertheless, it is important information from a country with history of vaccine hesitancy and a region with multiple health issues to tackle.

Conclusion
In summary, this survey indicates the overall acceptance of an anti-COVID-19 vaccination program and highlights important aspects to be included in engagement with national stakeholders and to be communicated in national information campaigns.
Religious beliefs also need to be taken into account while planning a communication strategy.

Consent
Consent from participants was taken, once they agreed only then the survey went further.

Availability of data
All the collected data is available with the corresponding author.

Competing interests
The authors declare that they have no competing interests.