Health-care staff beliefs and coronavirus disease 2019 vaccinations: A cross-sectional study from Iran

Mina Kianmanesh Rad; Ahmad Fakhri; LAR Stein; Marzieh Araban

doi:10.4103/shb.shb_13_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 5 | Issue : 1 | Page : 40-46

Health-care staff beliefs and coronavirus disease 2019 vaccinations: A cross-sectional study from Iran

Mina Kianmanesh Rad¹, Ahmad Fakhri¹, LAR Stein², Marzieh Araban³
¹ Department of Psychiatry, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
² Department of Psychology, University of RI, Kingston; Social/Behavioral Sciences and Center for Alc/Addic Studies, Brown University School of Public Health, Providence; Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, Cranston, RI, USA
³ Department of Health Education and Promotion, Public Health School, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

Date of Submission	18-Nov-2021
Date of Decision	21-Jan-2022
Date of Acceptance	27-Jan-2022
Date of Web Publication	25-Feb-2022

Correspondence Address:
Marzieh Araban
Department of Health Education and Promotion, Ahvaz Jundishapur University of Medical Sciences, Ahvaz
Iran

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/shb.shb_13_22

Abstract

Introduction: Health-care worker desire to receive coronavirus disease-2019 (COVID-19) vaccination can affect public perception and adoption of vaccination. The present study surveyed the health beliefs of health-care staff regarding COVID-19 vaccination. Methods: In this cross-sectional online survey conducted in Iran between May and June 2021, 537 health-care staff (73.8% females) participated. Health-care staff were assessed on the following constructs: health locus of control, trust in the health-care system, subjective norms, fear of COVID-19, attitude and feelings toward vaccination, physical distancing, intention to engage in preventative behaviors, and perceived behavioral control. Multivariate logistic regression models were used to examine the influence of demographic, clinical factors, fear of COVID-19, and health beliefs, in predicting openness toward vaccination. Results: About 67.5% of subjects received COVID-19 vaccination (first or second dose), with 57.2% reporting feeling confident in getting vaccinated and 32% expressing hesitancy in getting vaccinated. Trust in the health-care system, fear of COVID-19, and positive attitude toward vaccination were significantly higher in vaccinated participants than unvaccinated ones, P < 0.05. Conclusion: Being vaccinated and openness toward vaccination are influenced by health-care professionals' demographic and clinical characteristics, and health perceptions (i.e., fear of COVID-19). Whereas being overwhelmed with fear of COVID-19 is unadvisable, realistic concern balanced with appropriate action (e.g., vaccination) may be reasonable.

Keywords: Coronavirus disease 2019, health beliefs, health-care staff, Iran, vaccination

How to cite this article:
Rad MK, Fakhri A, Stein L, Araban M. Health-care staff beliefs and coronavirus disease 2019 vaccinations: A cross-sectional study from Iran. Asian J Soc Health Behav 2022;5:40-6

How to cite this URL:
Rad MK, Fakhri A, Stein L, Araban M. Health-care staff beliefs and coronavirus disease 2019 vaccinations: A cross-sectional study from Iran. Asian J Soc Health Behav [serial online] 2022 [cited 2023 Oct 5];5:40-6. Available from: http://www.healthandbehavior.com/text.asp?2022/5/1/40/338375

Introduction

Coronavirus disease 2019 (COVID-19) is a global threat.^[1] Home quarantining, mask use, and physical distancing have been recommended to reduce disease transmission. When not quarantining at home, physical distancing is also recommended to reduce transmission, but is rather impractical for health-care professionals to observe in medical settings.^[2],[3] The high mortality rate of COVID-19 and failure in preventing its spread highlighted the importance of an effective vaccine.^[4],[5] Increased skepticism, including delaying or refusing immunization, is a barrier to inhibiting the development of vaccine-preventable diseases.^[6],[7] Vaccine hesitancy is a term used to define refusal or reluctance to accept a vaccine despite the availability of such services.^[7] Long-term control of COVID-19 depends on the availability of an efficient vaccine,^[8] and the World Health Organization has approved many vaccines for COVID-19.^[9] The first emergency use authorization for COVID-19 vaccines was issued in December 2020 by the Food and Drug Administration for individuals over the age of 16 years.^[10] However, hesitancy toward COVID-19 vaccinations negatively affect otherwise effective vaccination programs.^[11],[12] Vaccine hesitancy undermines mass vaccination programs, leading to their failure and consequently making efforts to end the diseases like COVID-19 fruitless.^[13]

Considering the widespread prevalence of COVID-19, health-care workers are at great risk to developing the disease; hence, they were introduced as the first groups to receive the vaccine.^[10],[14] On the other hand, despite the efficacy and safety of COVID-19 vaccinations, there has been a low acceptance rate of them among health-care workers.^[15] For example, a study conducted in Los Angeles showed that 47.3% of health-care workers were reluctant to receive the vaccine and most of them (66.5%) intended to delay vaccination.^[8] One-fourth of medical students in the United States were skeptical of the COVID-19 vaccine.^[16] A survey of health-care staff in Saudi Arabia revealed that only 50.52% were willing to get the COVID-19 vaccine.^[17] Furthermore, health-care workers have been reluctant to participate in a governmental compulsory vaccination program.^[18]

It is critical to maintain the health of health-care personnel by increasing the acceptance of COVID-19 vaccines. It is important to discover factors related to favorable attitudes toward vaccination and getting vaccinated, including motivation and subjective norms for vaccination.^{[19],[20],[21],[22],[23]} Health-care worker desire to receive COVID-19 vaccination can affect public perception and adoption of vaccination.^[8] Therefore, a cross-sectional study among health professionals in Ahvaz, Iran, sought to identify demographic characteristics and health beliefs associated with COVID-19 vaccination status and attitudes.

Methods

Study design and participants

The present study was conducted as an online survey in the affiliated centers of Ahvaz University of Medical Sciences and Health Services in Iran. The self-administered questionnaire was created on the Press Line website and made available between May and June 2021. Research participants included general practitioners, medical students, and other health-care staff. Participants were invited to the survey through a link posted on the official websites and social networks (WhatsApp, Telegram) of the affiliated medical centers of the University of Medical Sciences and Health Services. Participation in the study was voluntary and anonymous. Inclusion criteria included: Working as a physician, medical student, resident, or staff/health-care team member of the affiliated medical centers of the University of Medical Sciences and Health Services; being within an age range of 18–60 years; having at least 1 year of formal or contract work experience in the field. Ultimately, 537 individuals participated in the study.

Measures

Background information

Items including age, gender, marital status, education, place of work, vaccination status, underlying diseases, having a child <12 years, and having someone in the participant's home at increased susceptibility (e.g., elderly) for COVID-19. Demographics may inform who to target for intervention to enhance interest in vaccination.

Health beliefs

A series of questions were asked to assess constructs related to health behaviors including local of control, perceived behavioral control (beliefs about the difficulty of enacting behavior), subjective norms, and intention to engage in preventive behavior. A vast literature illustrates usefulness of understanding such constructs in supporting health.^{[24],[25],[26],[27],[28]} Health locus of control was comprised of 1 question (sample item, “I am responsible for management of my health condition”) with response options on a Likert scale from 1 = strongly disagree to 5 = strongly agree. Total scores ranged 1–5.

Intention to engage preventive behavior was comprised of 2 questions (sample item, “I am going to adhere to COVID-19 preventive behaviors everyday”) with response options from 1 = strongly disagree to 5 = strongly agree, total score ranging from 2 to 10 and internal consistency (α) of 0.70.

Perceived behavioral control, comprised of 2 questions (sample item, “I do believe that, If I want, I can adhere to COVID-19 preventive behaviors”), had response options of 1 = strongly disagree to 5 = strongly agree with final score of 2–10 and internal consistency (α) = 0.60.

Subjective norms was comprised of 2 questions (sample item, “all those who are important to me are expecting me to adhere to COVID-19 preventive behavior”) and again response options were 1 = strongly disagree to 5 = strongly agree, and final score of 2–10 with internal consistency (α) = 0.70. Higher scores indicate more of each construct above. For example, higher score on subjective norms suggests norms more consistent with reduced COVID-19 risk.

Trust

Trust is foundational for a relationship between patients and clinicians, and enables patients to accept diagnoses and recommended treatment. Clinicians and health-care systems must be viewed as putting patient interests above self-interest, including financial self-interest.^[28] Therefore, trust in the health-care system was measured with 3 questions (sample item, “I trust the health-care system”) rated from 1 = strongly disagree to 5 = strongly agree, yielding a total score of 3–15 and internal consistency (α) = 0.70, where higher scores indicate more trust.

Vaccination fear, attitudes and feelings

Participant feelings about receiving the COVID-19 vaccine were assessed with an item that said, “Please choose the single response of the 4 following choices that best describes how you feel about getting a COVID-19 vaccination.” I would confidently get (or I have confidently gotten) a COVID-19 vaccination; I would hesitantly get (or I have hesitantly gotten) a COVID-19 vaccination; I would forcibly get (or I have forcibly gotten) a COVID-19 vaccination; or I would not at all consider getting (or I have not at all considered getting) a COVID-19 vaccination.

Attitude toward vaccination was comprised of 5 questions (“Getting vaccinated is useful”). Response options included a Likert scale from 1 = useless/undesirable to 5 = useful/desirable, with lower score indicating poorer attitudes and higher score indicating better attitudes toward vaccination. Total score ranged from 5 to 25 and internal consistency (α) = 0.95.

Fear of COVID-19 was measured with 7 questions (sample item, “I am most afraid of coronavirus-19.”) based on the work of Ahorsu et al.,^[18] with items rated from 1 = strongly disagree to 5 = strongly agree, final score of 7–35, internal consistency (α) = 0.90 and higher score indicating more fear.

Physical distancing

Because social distancing may impact perceptions on relevance of vaccination, 3 questions were asked to determine extent of physical distancing used by participants (“Do you adhere to the principles of social distancing?”). Each item was rated from 1 = always to 7 = never. Total score ranged from 3 to 21 and internal consistency (α) = 0.70, with higher scores indicating more frequent use of physical distancing.

Sample size estimation

The sample size was calculated according to a similar study examining factors affecting intention to get a COVID-19 vaccination in Iran.^[29] In this study, the acceptance rate for vaccination was reported as 64.2% in 4933 people. Considering the 95% confidence level and 5% margin of error, the minimum sample size needed in the current study was calculated as N = 330 (see below formula). However, 537 individuals participated in the study increasing power to detect smaller effect sizes.

Statistical analysis

Statistical analysis was performed using Windows-based SPSS software version 22 (IBM Corporation; New York, USA), and significance level was set at P < 0.05. Numeric and categorical data were presented with mean and standard deviation, and number and percentage, respectively. Independent t-tests were used to compare vaccinated and unvaccinated groups on health behaviors, beliefs, trust, vaccine attitudes and fear. Multivariate logistic regression models were used to evaluate demographic and clinical factors (e.g., gender, underlying disease) and more malleable psychological factors affecting vaccination willingness (i.e., fear of vaccination) among health-care professionals.

Ethics consideration

The study was approved by Ethics Committee of Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran (Registration No: IR.AJUMS.REC.1400.115). Written informed Consent was obtained from participants. All methods were performed in accordance with the relevant guidelines and regulations.

Results

Study population

Participants were 537 health-care professionals. [Table 1] presents participant characteristics. A little over half were under 35 years old, most were women, a little over half were married, just under half had a bachelor's degree, and just under 40% worked in a health-care facility. Also, just under 15% had an underlying disease, just over 40% had a child under 12 years and just over 35% had a susceptible person (e.g., elderly) in the home. First and second phases of vaccinations were conducted in 23.3% and 44.2% of this population, respectively.

Table 1: Participant characteristics

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Feelings regarding receiving the vaccine

Overall, participant feelings were positive and 57.2% expressed that they received or would receive the vaccine confidently. Receiving it hesitantly, forcibly or not at all were reported at the following rates by the sample, respectively: 32%, 3.6%, and 7.3%, respectively. Forcibly and not at all categories are combined for further analyses below.

Beliefs and behaviors concerning vaccination

Results presented in [Table 2] suggest that the beliefs and attitudes about health care (i.e., the system and vaccine) and the disease itself (i.e., fear of the disease) are more related to vaccination status than respondent behaviors or perceptions of behaviors (e.g., physical distancing, belief that health is under one's control). Trust in the health-care system was significantly higher in vaccinated individuals than in nonvaccinated ones (11.30 vs. 10.79, P = 0.038). Fear of COVID-19 was higher in the vaccinated group (18.96 vs. 17.60, P = 0.017). Vaccinated participants had a more accepting attitude toward vaccination than nonvaccinated persons (20.53 vs. 18.21, P < 0.0001).

Table 2: Evaluation of factors affecting coronavirus disease-2019 vaccination

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As shown in [Table 3], Model 1 (vaccine acceptance or resistance), the presence of underlying disease in participants negatively impacted vaccination acceptance. People without an underlying disease were at significantly greater odds to report acceptance/confidence than those with an underlying disease (odds ratio [OR] = 3.44, 95% confidence interval [CI] = 1.24–9.51). In Model 2 (vaccine acceptance vs. hesitancy), sex of participants was related to the vaccine acceptance/confidence. Women were more hesitant about vaccination than men (OR = 1.88, 95% CI = 1.11–3.18). In Model 3 (vaccine hesitancy vs. resistance), underlying disease and fear of COVID-19 were identified as significant factors. The presence of an underlying disease in participants was associated with an increased resistance to get vaccinated. Participants with no underlying disease were more likely to be hesitant (vs. resistant) toward vaccination than those with an underlying disease (OR = 5.05, 95% CI = 1.58–16.20). Participants with higher (rather than lower) levels of COVID-19 fear were more likely to be hesitant (vs. resistant) toward vaccination (OR = 3.89, 95% CI = 1.21–12.51).

Table 3: The logistic regression models for coronavirus disease-2019 vaccination

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Discussion

Although 32% of the health-care workers were hesitant about vaccination, 57.2% of them confidently accept COVID-19 vaccination. Overall, findings confirm the results of previous studies illustrating the low acceptance rate of vaccines for health-care providers during the COVID-19 epidemic.^{[7],[14],[15],[16]} In a similar study conducted in Iran, where 24.7% of the participants were health-care workers, the acceptance rate of vaccination was 64.2%.^[29] Employment in health-care centers exposing individuals to higher risk was ironically associated with lower desire for vaccination.^[29]

Unfortunately, this low level of desire for vaccination in health-care providers, who are viewed as medical experts, can adversely affect public attitude toward vaccination.^[30] It may be that exposure to vaccinated patients with severe complications instills doubt in health-care staff.^[29] Limited engagement of medical professionals and heads of the state in early roll-out of COVID-19 vaccination in the United Kingdom and the Unites States can be interpreted by the public as low confidence in vaccination safety.^[18] Similarly, lack of trust of many African-Americans in the health-care system has been a significant barrier to COVID-19 vaccination.^[31] Other studies have also reported a relationship between trust in the health-care system and effective vaccination rates.^{[32],[33],[34]}

Preventive behavior (i.e., physical distancing) and health beliefs reducing risk (e.g., intention to engage in preventive behavior) were high among participants in the present study, and no significant differences were observed between the vaccinated and unvaccinated participants on such factors. This suggests these professionals see themselves as responsible for reducing their risk (i.e., locus of control), see community members as supportive of action to reduce risk (i.e., subjective norms), intend to engage in behavior to prevent risk, believe that their preventive actions can be effective to reduce their risk, and take steps to reduce risk, such as physical distancing. At the same time, trust in the health-care system, including vaccination, and fear of COVID-19 were significantly lower in the unvaccinated group than in the vaccinated group. More work should be done to understand health-care workers' lack of trust in the profession. Increasing trust may allow some health-care professionals to view vaccination as a preventive option, especially in the presence of fear regarding getting COVID-19. Among a general sample of Iranians, fear of COVID-19 was associated with higher rates of vaccination, better attitudes toward vaccine acceptance, and subjective norms conducive to vaccine adoption.^[28]

In the present study, individuals without an underlying disease significantly reported more openness to vaccination compared to those with an underlying disease. Conversely, persons with an underlying disease were less open to vaccination. Such reluctance in persons with underlying disorders is based on perceptions that the vaccination will adversely impact health. However, in a study of health-care professionals, vaccination side effects in those chronic medical conditions were not life-threatening, and these professionals were able to carry out daily activities following vaccination.^[35] Findings also indicated women, compared to men, were more hesitant than accepting toward COVID-19 vaccination. Similar to our research, other studies examining general populations,^[33],[36] and health-care professionals^[17],[37] reported that women had lower confidence in the vaccination. A study by Askarian et al.^[29] in Iran also reported lower vaccination acceptance in women compared to men. Finally, fear of COVID-19 is related to increased odds of being merely hesitant toward vaccination as compared to being outright resistant toward vaccination. While fear does not appear to enhance confidence in the vaccination (i.e., acceptance), it apparently may be a motivating factor for persons who might otherwise resist vaccination altogether.

There is available instrument assessing acceptance to COVID-19 vaccination (i.e., drivers of COVID-19 Vaccination Acceptance Scale)^{[38],[39],[40]} might be used in future researches for comparing studies among different countries.

Limitations

Survey data were obtained during roll-out of COVID-19 vaccination programming in recruitment settings, and collecting data on beliefs and perceptions before such roll-out may have yielded different results. Future studies may wish to examine change over time in attitudes, beliefs, perceptions, and health behaviors before, during, and after vaccination programming in a setting. The current study did not examine perceptions, attitudes, and beliefs as related to specific vaccine types, which also may be of interest to future investigators.

Conclusion

The present study indicated that 57.2% of health-care providers have confidence in vaccination, whereas 32% are hesitant. Trust in the health-care system, including vaccination, and fears of COVID-19 were significantly lower among unvaccinated than vaccinated persons. Having relatively more fear of COVID-19, being male, and having no underlying disease related to relatively more openness to getting vaccinated for COVID-19. Health-care settings might foster discourse with staff (particularly women) on pros and cons of getting vaccinated versus not getting vaccinated and options for keeping safe (including vaccination) in the presence of underlying health problems. Staff may then see the health-care system as a collaborative source of information as they make complex health decisions for themselves, thereby enhancing trust in health care and vaccination. More work should be performed to better understand how to mitigate the lack of trust in the health-care system.

Acknowledgment

Hereby, we would like to appreciate the attempts made by all the observers who helped us conduct this project. Special thanks are extended to Prof. Amir H. Pakpour for his valuable comments on methodology. Moreover, the authors appreciate Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran, for the financial support.

Financial support and sponsorship

Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran, funded the study# U-00061. The fund was spent on preparing materials such questionnaires and data collection.

Conflicts of interest

There are no conflicts of interest.

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