Assessment of COVID-19 Vaccination Intention Among Community Health Workers: a Web-based Cross-sectional Survey During the First Wave of the Pandemic in India

Background: Vaccine hesitancy is of considerable concern as it threatens the great potential of a vaccine against COVID-19. Community health workers (CHWs) bridge the gap between the community and the health care system. Their intention to get vaccinated will not only affect them but will also affect the community’s perception of the vaccine. This study aims to understand the intention to get vaccinated against COVID-19 among community health care workers in India and its determinants. Methods: A web-based, cross-sectional study was conducted among 357 community health workers using snowball sampling. A self-administered anonymous questionnaire was shared with study participants across major geographical regions in India through social media during the rst wave (November-December 2020). Results: Among 357 community health workers, 208 (58%) responded positively regarding their intention to get a COVID-19 vaccine. Graduate [aOR 2.26 (95% CI: 1.27-4.01), p=0.006] and post-graduate participants [aOR 2.85 (95% CI: 1.43-5.68), p=0.003], those with lower risk perception [aOR 1.86 (95% CI: 1.03-3.35), p=0.038] and respondents who trusted the healthcare system [aOR 2.60 (95% CI:1.59-4.26), p<0.001] were more likely to get vaccinated. Respondents who were exposed to COVID-19 cases were less likely to uptake the hypothetical vaccine [aOR 0.57 (95% CI: 0.34-0.96), p=0.034]. Conclusions: Increasing knowledge regarding the COVID-19 vaccine might not be enough to improve vaccine acceptance rates. Enhancing trust among community health workers in the healthcare system and regarding the available vaccines seem necessary. In addition, targeted interventions addressing socio-demographic determinants related to COVID-19 vaccination should help improve acceptance of the vaccine.


Background
The ongoing Coronavirus disease-2019 (COVID-19) pandemic has affected over 173 million people and caused more than 3.7 million deaths globally [1]. Imposing enormous morbidity and mortality burdens, the disease continues to disrupt societies and economies across the globe. Around ten million people have been affected in India alone [2]. Working on the frontline, thousands of healthcare workers (HCW) have been infected and lost their lives in the pandemic [3,4]. Though exact numbers are not known, the Indian Medical Association (IMA) reported 665 physicians in India lost lives in the line of duty [5].
Over the past century, vaccines have become indispensable in eliminating and eradicating viral illnesses [6]. Besides preventing diseases among the immunized, vaccines have reduced infections in the population through herd immunity [7]. Following the much-awaited COVID-19 vaccine launch, an estimated one crore frontline health workers, including physicians, nurses, and community health workers, have been identi ed for receiving the vaccine in the rst phase. The government's focus on COVID-19 immunization is palpable as the nance minister allocated a massive ₹35,000 crores exclusively for the vaccines to bring an end to the pandemic [8].
Vaccine hesitancy is de ned as "delay in acceptance or refusal of vaccination despite the availability of vaccination services." [9] It is of considerable concern as it threatens the great potential of a vaccine against COVID-19. The WHO has identi ed "vaccine hesitancy" as one of the top ten threats to public health in 2019, globally [10]. Hesitancy and misinformation prevent the achievement of required vaccination coverage in India and in other countries. The situation is even worse following the introduction of a new vaccine. [11] Vaccine safety and e cacy, adverse health outcomes, absence of trust in the health system and lack of knowledge are some of the reasons reported by numerous researchers [12,13].
A systematic review reported the acceptance rate for H1N1 in uenza pandemic vaccine varied between 8% and 67% [14]. Acceptance rate of the COVID-19 vaccine, as reported by a global survey, was 72%. High heterogeneity was observed between 90% in China and less than 55% in Russia [15]. Community health workers (CHWs) involved in planning, identifying target groups, community engagement, service delivery, tracking, and follow-up in healthcare delivery activities. They are critical in introducing a new vaccine. These grass-root level workers are vital interlocutors. The knowledge of "last mile" health service delivery, shared lived experience that fosters trust and credibility within communities, and previous experience in vaccination makes them indispensable to the COVID-19 vaccination drive [16]. Their intention to get vaccinated will not only affect them but will also affect the community's perception about the vaccine.
Understanding key factors in uencing uptake of the vaccine by the CHWs may help policymakers to develop strategies for effective implementation. Since vaccine acceptance differs between countries, cultures, and due to the vaccine, itself, this study aims to understand the intention to get vaccinated against COVID-19 among community health care workers in India, and their determinants.

Methods
Study design, setting, and sample A cross-sectional survey was conducted across major geographical regions in India during the rst wave of the pandemic (November-December 2020). Community healthcare workers (N = 357) were contacted through snowball sampling. The sample size was calculated using the OpenEpi Version 3.01 with a hypothesized 65% ± 5% prevalence of vaccine acceptance at 95% con dence level. The design effect was kept one. The minimal sample size, which came on estimation at 95% con dence level, was 350. CHWs, aged 18 and above and willing to participate in the study were recruited for data collection.

Study Procedure
Web-based self-administered questionnaires were developed and shared with the participants through social media. The participants were requested to share the link with their peers in their circle. On clicking on the received link, the participants were auto-directed to the informed consent page. After providing informed consent, they were allowed to take the survey. The questionnaire consisted of sections on socio-demographic details, questions to understand knowledge, perception of risk of getting infected with COVID-19, trust in the health system, and willingness to accept the COVID-19 vaccine, once available. Intention to get vaccinated was assessed by the question "Do you intend to get vaccinated against Coronavirus when the vaccine is available?" followed by the response options, "yes," "no," and "not sure." Based on their response, they were asked why they intended/did not intend/were not sure to get vaccinated through pre-speci ed reasons followed by response options, "yes" and "no."

Data analysis
Participant characteristics were summarized using frequency (percentage). Chi square test was used to examine the distribution of intention to accept COVID-19 vaccine with respondents' socio-demographic characteristics. Logistic regression was used to identify association between independent variables and the intention to accept the vaccine. Odds ratios (OR) and their 95% con dence intervals (95% CI) were reported. A two tailed p-value < 0.05 was considered to be statistically signi cant. All data analysis was performed using STATA 13.0.

Discussions
This study is rst of its kind to depict the COVID-19 vaccination intention among community health worker in India. Of the 357 community health workers, just over half responded positively regarding intention to uptake COVID-19 vaccination. Education, exposure to COVID-19 cases, perception of risk, and trust in the healthcare system were factors which affected intention to get vaccinated.
More than half (58%) of the respondents showed their intention of getting vaccinated in the current study, however, this level of acceptance might not be su cient to break the chain of transmission [17,18]. In a survey conducted among French healthcare workers, 77% declared they would intend to get vaccinated against COVID-19 [19]. Rates of intention ranged from 92% in physicians, 65% among nurses, 70% among midwives and 67% in other HCWs [19]. Healthcare workers in Congo reported, around 28% were willing to get vaccinated [20]. In India, 86% planned to get COVID-19 vaccination whenever available, in a survey conducted among the general population [21]. The differences in study population and the time when the survey was conducted might explain the differences.
Having a graduate or a post-graduate degree was associated with higher intention of up taking the vaccine as compared to a diploma/ high school education in our study. This was similar to other studies who reported higher education was associated with greater uptake of the hypothetical vaccine [15,22].
Those participants who were exposed to COVD-19 cases were less inclined to uptake the hypothetical vaccine in the current study. This was in contrast to studies conducted among healthcare workers in Canada and China, where exposure or suspected exposure to a COVID-19 patient was associated with higher intention of acceptance [23,24].
Those who perceived they were not at risk of getting infected by COVID-19 were more likely to opt for a COVID-19 vaccine when it was available, in this study. Risk perceptions are central to many health behavior theories. Several studies have found positive association between risk perceptions and engagement in protective behavior like vaccination [19,25,26], while other studies have reported negative relationships [27]. It can be speculated that perceived control might have affected the study results. High levels of perceived control has been reported to be associated with lower health risk perception [28], and higher intentions towards protective behavior [29]. The role of perceived control as a moderator between perceived risk and vaccination intention could be explored in future studies.
In the current study, the odds of accepting the vaccine was almost three times more among those who trusted the healthcare system as compared to those who did not. A positive effect of trust in the health system and the government on vaccination intention and uptake has been reported previously [15,30,31].
This is the rst study as per our knowledge which has examined the intention to accept COVID-19 vaccine among community health workers in India. However, it has a number of limitations. The study was crosssectional in nature with convenience snowball sampling; the intention to uptake vaccine might change with time. Responses were recorded using an online survey which might have led to potential biases in reporting. Also, questions were available in English language and not in regional languages which might have prevented non-English speaking CHWs from participating.
Despite almost all participants having knowledge regarding the community circulation of the virus and the development of a COVID-19 vaccine, it is of considerable concern that just over half expressed their intention to uptake the vaccine once it's available. In a country like India, where community healthcare workers act as a bridge between the healthcare system and the general population, their recommendation plays an in uential role in the general population's vaccination behavior. The grass-root level workers serve as an important source of information for the community, and their perception of COVID-19 vaccination can be a key factor in in uencing the public's decision to get vaccinated. The low positive response regarding acceptance of a COVID-19 vaccine among the study participants is worrying. There is a signi cant need to address the CHW's vaccine related concerns and improve their trust in the healthcare system to increase acceptance rate of COVID-19 vaccine.

Conclusions
Increasing knowledge about COVID-19 disease and the vaccine is not enough to improve vaccine acceptance rates. It is necessary to improve trust in the country's health system and COVID-19 vaccines to win the ght against the disease. Vaccination campaigns should focus more on those with lower educational status.