https://orcid.org/0000-0002-1273-4779
ABSTRACT
Background
We assessed willingness to accept vaccination against coronavirus disease 2019 (COVID-19) among healthcare workers(HCWs) at the start of South Africa’s vaccination roll-out.
Research Design and Methods
We conducted a cross-sectional survey among HCWs in Cape Town in March-May 2021 and assessed predictors of vaccination intentions.
Results
We recruited 395 participants; 64% women, 49% nurses, and 13% physicians. Of these, 233(59.0%) would accept and 163 (41.0%) were vaccine hesitant i.e. would either refuse or were unsure whether they would accept COVID-19 vaccination. People who did not trust that COVID-19 vaccines are effective were the most hesitant (p = 0.038). Older participants and physicians were more likely to accept vaccination than younger participants (p < 0.01) and other HCWs (p = 0.042) respectively. Other predictors of vaccine acceptance were trust that vaccines are compatible with religion (p < 0.001), consideration of benefits and risks of vaccination (p < 0.001), willingness to be vaccinated to protect others (p < 0.001), and viewing vaccination as a collective action for COVID-19 control (p = 0.029).
Conclusions
COVID-19 vaccine hesitancy is high among HCWs in Cape Town. Reducing this would require trust-building interventions, including tailored education.
1. Introduction
A high uptake of vaccines is required for control, elimination, and global eradication of vaccine-preventable diseases [Citation1]. By March 2021, several vaccines against coronavirus disease 2019 (COVID-19) had been approved for emergency use in many countries around the world, including South Africa [Citation2]. Prior to the rollout of COVID-19 vaccines in South Africa, the country conducted an open label phase 3b implementation research study from February to May 2021 during which the single-dose Ad26.COV2.S viral-vectored COVID-19 vaccine was made available to healthcare workers (HCWs) [Citation3–5]. The implementation research study was necessary to maintain a healthy workforce to deal with the third wave of COVID-19 infections in the country, which was predicted to start in May-June 2021 [Citation3].
HCWs are a diverse group of people whose job is to protect and improve the health of their communities [Citation6]. They face a high occupational risk of becoming infected and dying from COVID-19 [Citation7]. HCWs have also been at increased risk of psychological distress and unfair treatments during the COVID-19 pandemic [Citation8–12]. For example, a systematic review by Olashore and colleagues found that HCWs in Africa have manifested a wide range of psychiatric disorders and general psychological distress during the COVID-19 pandemic [Citation8]. HCWs have also experienced high levels of burnout and stigma during the pandemic [Citation11]. Therefore, ensuring the protection of HCWs was a crucial element of South Africa’s response to the COVID-19 crisis [Citation13]. That is why HCWs were prioritized for early access to COVID-19 vaccination in the country [Citation3].
Access may not be the only barrier to optimal uptake of COVID-19 vaccines, so making vaccines available to HCWs may not necessarily translate to high uptake. A systematic review of surveys conducted among the general population in South Africa from February 2020 to March 2021 found variability in the levels of COVID-19 vaccine acceptance in the country, with acceptance ranging from 52% to 82% [Citation14]. However, none of these surveys focused on HCWs [Citation14]. In February 2021, when the early-access vaccine implementation study started [Citation3], little was known about the levels and drivers of COVID-19 vaccine acceptance and hesitancy among HCWs in South Africa. Vaccination attitudes of HCWs are important determinants of both their own vaccination uptake and their intention to recommend vaccination to others [Citation15–18]. We therefore initiated this study to understand the extent and determinants of COVID-19 vaccine acceptance and hesitancy among HCWs in Cape Town, as a first step in efforts to understand and address vaccine hesitancy among HCWs in South Africa.
2. Patients and methods
2.1. Study design and setting
This was a cross sectional survey conducted among HCWs living in Cape Town in South Africa. All HCWs living in the city were eligible for inclusion in the study. Based on best practice recommendations for scale validation and exploratory factor analyses, we estimated that we needed a sample size of 300 participants [Citation19]. This sample would allow for detection of small correlations (r = 0.2) with at least 95% power [Citation19]. We obtained approval from the University of Cape Town’s Human Research Ethics Committee (Reference Number: 858/2020) and permissions from relevant authorities in the Western Cape Provincial Department of Health (Reference Number: WC_202101_014). Participants were recruited through healthcare facility managers and e-mail lists and WhatsApp groups of HCWs across the city of Cape Town. The survey included a one-page consent form explaining the rights of the participants and the voluntary nature of participation in the study. Participants completed hard-copy questionnaires only after providing written informed consent through signing the one-page consent form. The online questionnaire was only activated once the participant consented to participate in the study by selecting the ‘accept’ option. If the ‘decline’ option was selected, the questionnaire was not activated, and no further information was collected.
2.2. Data collection
We collected data between 15 March and 27 May 2021. The survey instrument had questions on sociodemographical characteristics as well as COVID-19 vaccination attitudes and behavior. The sociodemographical information collected included date of birth, HCW role, sex, education, personal income, and religion. The questionnaire was in English.
For attitudes to COVID-19 vaccination, we contextualized 15 questions published in 2018 by Betsch and colleagues for measuring five psychological antecedents of vaccination (the 5 C scale): confidence, complacency, constraints, rational calculation of pros and cons, and collective responsibility [Citation20]. A subsequent paper will focus on the adaptation and validation of the 5 C scale. In addition to the 5 C questions, we asked whether COVID-19 vaccination was compatible with the participant’s religion and if the participant would receive the COVID-19 vaccine when it becomes available. Finally, since the survey commenced at the same time as the COVID-19 vaccine early-access implementation study [Citation3], we asked if participants had received the COVID-19 vaccine. The full questionnaire we used in the study is provided in .
Table 1. Questionnaire
Participants completed the consent form and questionnaire either as a hardcopy (provided to healthcare facilities) or an online form (sent to them through e-mail or WhatsApp) linked to the REDCap software on the University of Cape Town’s server. All responses were anonymous and no participant-identifying information was recorded.
2.3. Data management
The explanatory variables consisted of 23 questions or statements (six on sociodemographic characteristics and 17 on attitudes to COVID-19 vaccination).
We treated the sociodemographical variables as follows. We transformed age from a continuous to a categorical variable (18–24, 25–34, 35–44, 45–54, 55+) to be able to examine differences between specific age groups. We grouped HCW roles into administrative support, nurse, physician, and other HCWs to reflect the risk related to the function. We also stratified highest educational attainment into three categories: below high school, high school graduate, and university (from bachelor to PhD). We grouped religion into Christian, Muslim, other religions (African Spirituality, Hindu, Buddhist, Jewish, etc.), and none. For personal income per month, we maintained the categories in the questionnaire i.e. less than 10,000.00 Rand, between 10,000.00 and 50,000.00 Rand, and more than 50,000.00 Rand. In mid-2021 the exchange rate was One United States (US) Dollar to 14 South African Rand.
Each of the 17 vaccine attitude statements had seven response options: 1 for strongly disagree, 2 for moderately disagree, 3 for slightly disagree, 4 for neutral, 5 for slightly agree, 6 for moderately agree, and 7 for strongly agree. We shortened these to three categories as follows: 1 to 3 were categorized as ‘no,’ 4 as ‘neutral,’ and 5 to 7 as ‘yes.’
Our outcome variable was the intention to receive a COVID-19 vaccine. This was measured in the questionnaire by the statement ‘I will take the COVID-19 vaccine when one becomes available.’ This statement had seven response options: 1 for strongly disagree, 2 for moderately disagree, 3 for slightly disagree, 4 for neutral, 5 for slightly agree, 6 for moderately agree, and 7 for strongly agree. We transformed the seven responses to a binary variable; with responses 1 to 4 categorized as ‘vaccine hesitancy’ and 5 to 7 as ‘vaccine acceptance.’ This dichotomization of Likert scale responses for COVID-19 vaccine intentions has been used by other surveys [Citation14,Citation21,Citation22].
2.4. Statistical analyses
We assessed the predictors of COVID-19 vaccine acceptance versus vaccine hesitancy. We calculated proportions for categorical variables and means (and their standard deviations) for normally distributed continuous variables. We built a multivariate logistic regression model assessing the association between sociodemographical variables and vaccine intention, followed by models assessing the association between sociodemographical variables and each ‘vaccination attitude’ variable separately. As a result of this process, we fitted models adjusted for age (as a continuous variable) and sex to assess independent predictors of COVID-19 vaccine intention among HCWs in Cape Town. All statistical analyses were processed with the software R version 4.0.4. The models were built using the generalized linear model for logistic regression in R/finalfit.R,1.0.3 package. All p-values reported in this article are two-sided.
3. Results
3.1. Sociodemographical characteristics
A total of 414 questionnaires were completed. However, nine records were duplicates and ten had incomplete information on age and sex. These 19 records were excluded from the statistical analyses. The sociodemographical characteristics of the 395 study participants are shown in . The mean age of the participants was 39 years (standard deviation 12 years) with half of them aged between 25 and 44 years old. Most of the participants were women (64%). Nearly all the participants (97%) had graduated from high school, with half of them (48%) having a university degree. While the role of respondents spanned the entire spectrum of care, nurses constituted the majority (49%) and 13% were physicians. Nearly two thirds of the participants reported personal monthly income between 10,000 and 50,000 Rands. Finally, in terms of religion, nearly three quarters (71%) were Christians with 7% not providing a response to the question on religion.
Table 2. Sociodemographical characteristics of study participants
3.2. Attitudes toward COVID-19 vaccination
shows the percentages of the study participants with various attitudes toward COVID-19 vaccination. Regarding confidence in COVID-19 vaccination and the health system that delivers it [Citation19], 47% believed that COVID-19 vaccines were safe; 46% that COVID-19 vaccination were effective; and 59% that public authorities made vaccine decisions in the best interest of the community. In addition, 54% of participants believed that COVID-19 vaccination was compatible with their religion.
Table 3. Attitudes toward COVID-19 vaccination among study participants
For complacency [Citation19], 9% of participants reported that COVID-19 vaccination was unnecessary because COVID-19 was not common; 17% believed that their immune system was strong enough to protect them against COVID-19 infection; and 11% believed that COVID-19 infection was not severe enough to warrant vaccination.
Regarding constraints [Citation19], 13% reported that everyday stress would prevent them from getting vaccinated; 17% believed that it was inconvenient to receive vaccinations; and 21% reported that visiting the vaccination clinic would make them feel uncomfortable.
When it comes to risk calculation [Citation19], 77% reported that they would weigh the benefits and risks before making a decision about COVID-19 vaccination; 70% indicated that they will closely consider each COVID-19 vaccine dose whether it is neccessary; and for 77% it was important to fully understand the topic of vaccination before taking COVID-19 vaccines.
Lastly, regarding collective responsibility [Citation19], 68% indicated that even if most people are vaccinated against COVID-19 they would still get the vaccine; 73% reported that they would want to be vaccinated against COVID-19 in order to protect people with weaker immune systems; and 78% regarded vaccination as a collective action to prevent the spread of COVID-19.
3.3. COVID-19 vaccination intention and behavior
Of the 395 participants, 233 (59.0%) were willing to accept the COVID-19 vaccine while 163 (41.0%) were hesitant. Nearly one-third (32%) reported that they had already received the COVID-19 vaccine at the time they completed the questionnaire.
3.4. Predictors of COVID-19 vaccine acceptance versus hesitancy
displays the results of logistic regression models showing the predictors of COVID-19 vaccine acceptance versus vaccine hesitancy among study participants. Physicians were more likely to accept COVID-19 vaccination than administrative support staff: odds ratio (OR) 5.84, 95% confidence interval (CI) 1.24 to 42.89, P = 0.042. Willingness to accept vaccination was also substantially higher among participants aged 55–78 years (OR 7.39, 95% CI 1.98 to 31.01, P = 0.004), 45–54 years (OR 5.56, 95% CI 1.96 to 17.32, P = 0.002), and 35–44 years (OR 5.71, 95% CI 2.21 to 16.39, P = 0.001) compared to participants aged 18–24 years. Participants who had already received COVID-19 vaccine were more likely to report that they were willing to take the vaccine (OR 5.65, 95% CI 2.36 to 14.5, P < 0.001). In addition, other predictors of COVID-19 vaccine acceptance were the belief that COVID-19 vaccines were compatible with religion, authorities had the best interest of the community at heart, COVID-19 vaccination was necessary, it was not inconvenient to be vaccinated, it was important to weigh benefits and risks of vaccination before making a decision, and that it was important to fully understand the topic of vaccination before getting vaccinated. The odds of COVID-19 vaccine acceptance were also substantially higher among participants who believed that even when most people are vaccinated against COVID-19 they must still get vaccinated (OR 5.95, 95% CI 2.45 to 14.67, P < 0.001). Similarly, vaccine acceptance was substantially higher among participants who wanted to be vaccinated in order to protect people with weaker immune systems (OR 7.88, 95% CI 3.01 to 22.08, P < 0.001) and those who considered vaccination as a collective action for the control of COVID-19 (OR 2.93, 95% CI 1.15 to 8.00, P = 0.029). However, HCWs who did not believe that COVID-19 vaccines were effective were less likely to accept the vaccines (OR 0.20, 95% CI 0.04 to 0.90, P = 0.038).
Table 4. Predictors of COVID-19 vaccine acceptance versus vaccine hesitancy among study participants
4. Discussion
Vaccine hesitancy represents a motivational state of being conflicted or opposed to vaccination [Citation23]. In this article, we have reported the findings of a cross-sectional study of COVID-19 vaccine hesitancy among HCWs in Cape Town in South Africa. We found the prevalence of COVID-19 vaccine hesitancy to be 41% in this diverse group of HCWs that included physicians, nurses, biomedical scientists, allied HCWs, hospital administrators, and others. The prevalence of 41% among HCWs is quite high, when compared to the prevalence of 24% found in the general population in the South African National Income Dynamics Study – Coronavirus Rapid Mobile Survey conducted at the same time as our study [Citation24]. In comparison, a systematic review of studies published by July 2021 found a similarly high prevalence of 40.8% for vaccine hesitancy among HCWs in the US [Citation25]. Other countries have also reported high levels of vaccine hesitancy among HCWs. For example, a study conducted between September and November 2020 in Taiwan found the prevalence of vaccine hesitancy among HCWs to be as high as 76.6% [Citation26].
Age and occupation seems to play a role in vaccine hesitancy among HCWs, with older participants and physicians being the groups most likely to accept COVID-19 vaccination. A systematic review by Yasmin and colleagues also reported occupation to be a predictor of COVID-19 vaccine hesitancy among HCWs, with acceptance varying from a low of 45% among nursing staff to a high of 90% among staff and students of a university medical center [Citation25]. A systematic review of surveys conducted among the general population in South Africa found that COVID-19 vaccine hesitancy was potentially influenced by age, education, and occupation [Citation14]. Our study and others confirm the influence of age and occupation on COVID-19 vaccine acceptance among HCWs [Citation27].
Trust also plays a key role in vaccine hesitancy among HCWs; with confidence in the safety and effectiveness of vaccines as well as confidence in the intentions of vaccine decision makers emerging as important predictors of vaccine acceptance. Our study results are consistent with findings from multiple settings that have shown that trust plays a major role in COVID-19 vaccine acceptance [Citation28–30]. Another important determinant of COVID-19 vaccine hesitancy is religion, with participants who believe that vaccines are compatible with religion most likely to accept vaccination [Citation31]. Collective responsibility also emerges as an important determinant, with participants wanting to be vaccinated in order to protect people with weaker immune systems and also because they regard vaccination as a collective effort to control COVID-19 [Citation20]. Other factors that substantially influence vaccine intentions include complacency and risk calculation [Citation32–34].
Our study confirms the findings reported by Cooper and colleagues that concerns regarding safety and effectiveness are important predictors of COVID-19 vaccine hesitancy. However, anxieties about vaccine safety and effectiveness are not unique to South Africa or COVID-19 vaccines. Comparable concerns have been extensively documented in studies on COVID-19 vaccine acceptance in other settings [Citation21,Citation22,Citation25,Citation26,Citation35] and the vaccine hesitancy literature more broadly [Citation36,Citation37]. Concerns regarding vaccine safety may be heightened for COVID-19 vaccines by the unprecedented speed with which they went through clinical testing [Citation2]. It took less than 12 months for several COVID-19 vaccines to move from phase 1 clinical trials to emergency use approval, an unprecedented speed in vaccinology.
The unfounded belief that approved COVID-19 vaccines are unsafe may also be driven by social media. A cross-country regression framework shows that at a country-by-country level, the use of social media to organize offline action is highly predictive of the belief that vaccinations are unsafe, with such beliefs mounting as more organization occurs on social media [Citation38]. In addition, disinformation campaigns online are associated with an increase in negative discussion of vaccines on social media and a drop in mean vaccination coverage over time [Citation38]. Thus, disinformation on social media in the context of COVID-19 may increase the number of HCWs who are hesitant about getting a vaccine, even if their fears have no scientific basis.
In the fight against COVID-19, it is important to address vaccine hesitancy among HCWs because HCWs are more likely to recommend vaccination if they themselves are vaccinated. For example, a study among nurses registered in continuing professional education courses at a large university in the United Kingdom showed that nurses who were vaccinated against influenza were more likely to recommend vaccination to their peers and patients [Citation15]. A Nigerian study similarly reported that female nurses were more likely to recommend human papillomavirus vaccination when they expressed a willingness to be vaccinated themselves [Citation39]. In addition, a Canadian study found that midwives who reported being immunized themselves were more likely to have trust in the safety and efficacy of influenza vaccines, and subsequently recommended vaccination to their colleagues and patients [Citation16]. Finally, there are multiple studies on different vaccines showing that recommending vaccination to coworkers, patients, and families was associated with HCWs themselves being vaccinated [Citation17,Citation18,Citation40].
It is thus important to listen respectfully to HCWs’ concerns regarding COVID-19 vaccines, to understand and address them with tailored education and context-specific messages. Numerous studies have found that appropriate knowledge increases HCWs’ willingness to receive vaccines and to recommend them to others. For example, one study in the United Kingdom reported that nurses with high knowledge scores on vaccines and vaccination were more likely to recommend vaccination to their colleagues and be willing to recommend vaccination to patients in the future [Citation41]. Similar findings were reported from a study in Cameroon, which revealed that HCWs were more likely to recommend vaccination if they had confidence in the safety and efficacy of the vaccine [Citation42]. These findings are consistent with those of many other studies across different settings [Citation40,Citation43,Citation44]. It is therefore important to listen proactively, understand, and engage HCWs with tailored tactics to reduce vaccine hesitancy and improve vaccination uptake among this population, which is at high risk of COVID-19.
The 5 C scale that we contextualized and used in this study, was developed and validated by Betsch and colleagues through a systematic review of existing literature, socio-behavioral and psychological theoretical considerations, and empirical testing in Germany and the US before the onset of the COVID-19 pandemic [Citation20]. From an African perspective, a key limitation of the 5 C scale is that it is based on research and theoretical modeling conducted in high-income countries [Citation36,Citation45]. This potentially limits its generalizability as vaccine hesitancy is known to be context-specific [Citation45]. In a subsequent paper, we will report the adaptation and validation of the 5 C scale for measurement of vaccine hesitancy in South Africa.
A validated vaccine hesitancy measurement tool is useful for measuring vaccine hesitancy and its determinants, monitoring changes and trends over time, enhancing the comparability of research results, and facilitating the development and evaluation of relevant and more theory-driven, evidence-informed and contextually-tailored interventions to address vaccine hesitancy [Citation46]. Currently available instruments for measuring the drivers of COVID-19 vaccination include the Motors of COVID-19 Vaccination Acceptance Scale as well as the Measuring Behavioral and Social Drivers of COVID-19 Vaccination tool [Citation45,Citation47–50].
Our sample of 395 participants provided enough power for our statistical computations, but a bigger sample size would have strengthened the findings. Although we made every effort to recruit a diverse group of HCWs in the city of Cape Town, we are mindful of the fact that representative sampling is a very complex endeavor and is highly context specific. Consistent with the general HCW population in South Africa, the majority of HCWs in our study were women and nurses. We therefore believe that this paper expands the scientific evidence base on vaccine acceptance and hesitancy among HCWs in South Africa. The paper also provides invaluable insight to enable a better understanding of, and response to COVID-19 vaccine hesitancy in the country and above all, increase vaccine uptake.
5. Conclusion
Most of the predictors of COVID-19 vaccine hesitancy in this study are related to a misunderstanding of the vaccine and its efficacy, suggesting that education could improve vaccine confidence and increase acceptance within this critically important population.
Declaration of interest
Charles Shey Wiysonge, Patrick de Marie C Katoto, and Sara Cooper are supported by the South African Medical Research Council. Samuel Alobwede is supported by Partners in Sexual Health, Cape Town, South Africa. Elvis Kidzeru is supported by the University of Cape Town Faculty of Health Sciences (FHS) Postdoctoral Fellowship Award, and the University of Cape Town Research Committee Award. Evelyn Lumngwena is funded by the Carnegie Corporation of New York through the Developing emerging academic leaders (DEAL-1) in Africa and National Research Foundation (NRF) of South Africa (DST-NRF) free standing innovation postdoctoral fellowship. Rene Goliath and Amanda Jackson are supported by the Wellcome Centre for Infectious Disease Research in Africa (CIDRI-Africa) at the University of Cape Town in South Africa. Muki Shey is supported by the Wellcome Trust Intermediate Fellowship (Grant#: 211360/Z/18/Z) and the National Research Foundation of South Africa (Grant#: 127558). The authors have no other 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 the manuscript apart from those disclosed.
Reviewer disclosures
Peer reviewers on this manuscript have received an honorarium from Expert Review of Vaccines for their review work, but have no other relevant financial relationships to disclose.
Author contributions
CSW, SMA, SC, and MS conceived and designed the study; SMA, PdMCK, EBK, ENL, RG, and AJ were involved in data collection and statistical analyses; and all authors were involved interpreting the findings. CSW, SMA, and PdMCK wrote the first draft of the manuscript; EBK, ENL, SC, RG, AJ and MSS revised the manuscript critically for intellectual content; and all authors approved the final version of the manuscript for publication.
Acknowledgments
The authors acknowledge their respective institutions for supporting their work.
Correction Statement
This article has been republished with minor changes. These changes do not impact the academic content of the article.
Additional information
Funding
References
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