The current survey, led between the 7th and the 21th of January 2021, revealed that 51.9% (95% CI: 47.5–56.3) of the Tunisian health professionals hesitate to uptake vaccine against SARS-COV2. Being affected in the south or in the central of Tunisia, the female gender and the fear of components in the upcoming vaccines predicted more hesitancy among them. While a previous episode of SARS-COV2 infection and the use of the national site for information about COVID19 predicted less hesitancy among them.
Results of the current study should be interpreted with taking into account some limits. Firstly, the cross sectional nature of the study did not allow to report causal relationships but only statistical associations. Besides, random sampling was not possible as no lists of national or regional health professionals were available. However, the required sample size was reached. In addition, the main categories of the health professionals were represented. Finally, attitudes and perceptions were self-reported by participants, this might lead to a social desirability bias. However, data were collected anonymously and participation was voluntary.
The hesitancy rate (51.9%) revealed by the current study was higher than that reported after an online opinion survey conducted almost at the same period (between the 10th and the 20th of January 2021) and which showed a lower hesitancy rate of 33.6% but higher refusal rate of 23.5% (17). This opinion survey was conducted by the “BEDER Association for Citizenship and Fair Development” with five questions about the age, the field of activity, the intention and the motivation to get the vaccine and its recommendation for others. Results of the survey were published on the website of the association (SAUVE.tn) while precisions about the methodology of this online opinion survey were not reported (17). Among our participants, 59.2% were physicians, 15.8% were dentists, 14.2% were pharmacists and 10.8% were from the paramedical stuff which was not far from the opinion survey (17). The French language of the questionnaire may explain the reluctance among some categories of the paramedical staff to respond to the survey. An available national updated contact list of the Tunisian health professionals is necessary to allow wider periodic evaluation of the willingness to get the vaccine against the SARS-COV2. In this way, policy makers would be able to adapt their information strategy.
Otherwise, the low rate of vaccine acceptance among participants (35.5%) joins that in USA (36%)(18), France (25.9%)(19), Italia (26%)(11) and the Democratic Republic of the Congo (27,7%)(20) while it is lower than those in Egypt (45.9%) (21), Malta (52%) (22) and Greece (78.5%) (23).
Females represented 70.2% of participants. The trend of feminization in the Tunisian health sector may explain somewhat this female predominance (24). Analyzing hesitancy among participants according to the gender showed that female gender is a predictor of hesitancy among health professionals towards the SARS-COV2 vaccine. This result is harmonious with the majority of previous similar studies (12). The higher male acceptance of vaccine may be due to an innate male propensity for risk taking towards the novel vaccine (25).
Older respondents were significantly less hesitant to uptake the SARS COV2 vaccine. While having a chronic condition or allergy did not seem to contribute to this hesitancy among them. A recent scoping review reported that individuals of older age are more likely to accept COVID-19 vaccines (12). This was explained by a perception of greater vulnerability to SARS-COV2 infection but also by higher education and greater experience in healthcare (12).
Health professionals from different Tunisian regions responded to our questionnaire. Thirty-nine point eight were working in the north, 38.1% in the center and 21.3% in the south. Having its professional activity far from the north of the country (where is located the capital) predicted more hesitancy among participants. In line with this result, lower vaccination rates among deprived groups were observed in several surveys (18, 20, 26). More efforts should be provided in the Tunisian interior regions to overcome regional disparities in terms of vaccination against SARS-COV2.
Professionals from private sector were significantly less hesitant to get the SARS-COV2 vaccine. This joins the results of a study led in Hong Kong (27). This may be explained by economic reasons as in private sector sick leave in case of COVID19 episode is not regularly paid.
Having been previously infected by SARS-COV2 predicted less hesitancy among participants. A study conducted in Saudi Arabia among healthcare workers did not show significant association between previous personal SARS-COV2 infection and willingness to receive a COVID-19 vaccine (28). Otherwise, among Italian patients recovered from COVID-19, the majority were hesitant or undecided towardsSARS-CoV-2 vaccine (11, 29). Similar result was reported in Chicago(30). Lack of knowledge concerning the duration of protection against the SARS-COV2 after infection may explain this fluctuation between countries (31).
Among participants, 81.7% reported lack of information about SARS-COV2 vaccines. Social media was the most source of information reported by participants which joins the results of the Egyptian study (21). Use of social media and lack of information about the SARS-COV2 vaccines were significantly associated with more hesitancy among participants. These results corroborate those in the healthcare workers of Egypt and Italia (11, 21). Fear from harmful components was significantly associated with vaccine hesitancy among participants. In fact, doubts concerning the vaccines safety seems to be a global phenomenon that influence vaccine uptake as it was mentioned in Italy (11), Democratic republic of Congo(20), Egypt (21)and Malta(32). Otherwise, the use of the official national web sites (Pasteur institute of Tunis and COVID19.tn) was significantly associated with less hesitancy rates among participants. Similarly, in Saudi Arabia, healthcare workers who used the Centers for Disease Control and Prevention website to seek valid information about COVID-19 vaccines were 1.5 times more likely to accept potential vaccine candidates than those who used other sources of information (28). Indeed, improved information on vaccines has been shown to increase vaccines’ acceptance (33).
The campaign of vaccination against SARS-COV2 began in Tunisia two months after the current study. At the 50th day of this campaign, it was reported in the Facebook page of the Tunisian Ministry of Health that 1.467.558 peoples have subscribed to get the vaccine via the website: EVAX.tn and only 400.363 doses of vaccines were obtained. While, 94.880 received the two doses of the vaccine. However, no reports were available at the official website of the ministry (34). Besides, the Tunisian pharmaco-vigilance website did not report any statistics about the side effects recorded among the vaccinated peoples (35). Furthermore, proportion of health professionals that were vaccinated until now is not available. Although, there is scarcity of COVID-19 vaccines in Tunisia in addition to poor resources explaining the slowness of vaccination, an effective information strategy should be implemented as soon as possible. Facebook may represent a good channel for disseminating valid messages and tackling misinformation especially that Facebook is the most social media used in Tunisia (16). This would ensure rapid coverage of the population when the vaccines will be more affordable. Engaging health care professionals in social media to counter the vaccine related misinformation would boost the national information strategy. In addition, reporting the results of the pharmaco-vigilance surveillance would improve the vaccine acceptability among health professionals and the general population as well. More attention should be paid to female health professionals, the youngest ones and those in the regions far from the capital. A special network designed for the Tunisian health workers would facilitate access to them and getting feed back from them in return. The SAUVE.tn website may represent a suitable basis for this network.
Otherwise, regarding the emergence of new strains of SARS-COV2 and the slowness of the vaccination process, reinforcement of the non-pharmaceutical interventions is necessary until sufficient coverage by vaccination will be reached in Tunisia. This underlines once again the necessity of an effective information strategy with multi-sectorial actions and a lobbying for a global COVID-19 vaccine equity.