COVID-19 vaccine acceptance among health care professionals in Ethiopia: A systematic review and meta-analysis

ABSTRACT

Low vaccine acceptance remains a public health threat, which is still common among healthcare workers. Therefore, the purpose of this review is to determine the level of COVID-19 vaccine acceptance among healthcare professionals in Ethiopia. This review was reported using the PRISMA checklist. Eleven articles were retrieved, then extracted on Excel, and exported to STATA version 11 software for meta-analysis. The pooled prevalence of vaccine acceptance and it is 95% CI were presented using forest plots. Tests to check heterogeneity and publication bias were done. The estimated pooled prevalence of COVID-19 vaccine acceptance among healthcare professionals in Ethiopia with a random-effects model was 54.59% (95% CI: 42.49, 66.69) through a heterogeneity index (I²) of 99.1% (p < .001), which is relatively low. Therefore, it is important to identify and remove any myths or obstacles preventing healthcare professionals from accepting the COVID-19 vaccination.

KEYWORDS:

• COVID-19
• vaccine acceptance
• healthcare professionals
• Ethiopia

Introduction

Coronavirus disease 2019 (COVID-19) is a lethal contagious disease caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is mainly transmitted from human to human through respiratory droplets¹. It is the global pandemic which was first identified in Wuhan, China, at the end of December 2019.² COVID-19 remains a worldwide challenge and it has been stated to be a global community health emergency.³ Besides substantial morbidity and mortality, it also causes an extensive economic crisis around the globe.^4,5

Now a time, several vaccines have received approval from the regulatory authorities and are being given in most countries, including Ethiopia, to end the global pandemic.⁶ However, experts concur that mass vaccination campaigns are the best way to build up enough “herd immunity” to control the epidemic. Convincing citizens that vaccines are safe, effective, and necessary is a critical component of an effective vaccination program. Evidence suggests that front-line healthcare professionals (HCPs) COVID-19 test results have an 11-fold higher positive rate than those of the general public.⁷ Because of this risk, the World Health Organization (WHO) advisory committee recommended that HCPs receive priority vaccination.⁸

Vaccine acceptance is defined as “the degree to which individuals accept, question, or refuse vaccination.” It is a determinant of vaccine uptake rate, and consequently vaccine distribution success.⁹ There is considerable evidence between vaccine acceptance among HCPs and the general public, as health professionals are trusted sources of information on public health concerns. Higher vaccination rates are attained by clients under the care of HCPs who have favorable views and acceptance of vaccinations.^10–13 The WHO designated vaccine hesitancy as one of the 10 threats to global health in 2019.¹⁴ Surprisingly, in the era of COVID-19, the problem is significant even among healthcare workers.¹⁵ A rapid systematic review of global vaccine acceptance among HCPs ranged from 28% to 73%.¹⁶ If health professionals continue to be dubious of COVID-19 vaccines, they will be unable to recommend vaccines to the general public and ensure mass vaccinations with the available COVID-19 vaccines.¹⁷ Lastly, they do not have a role in instilling confidence in the general population about vaccine safety and efficacy.^11,18

In Ethiopia, low vaccine acceptance forms a major challenge to the uptake of COVID-19 vaccines.^19,20 Reports from observational studies have shown the problem is significant even among HCPs.^21–24 However, no comprehensive reviews or meta-analyses of HCPs have been conducted to date. As a result, we sought to assess the HCP acceptance level of the COVID-19 vaccine in Ethiopia. The finding will allow stakeholders to create effective awareness to increase COVID-19 vaccine uptake in the country.

Methods

Search strategies

This systematic review and meta-analysis were reported using the preferred reporting items for systematic reviews and meta-analyses protocols (PRISMA) checklist guidelines¹⁸ (see S1_file). We registered the protocol into PROSPERO (ID: CRD42022332702) and searched for related papers in African journals online, PubMed, Cochrane review, HINARI, Google Scholar, and Web of Science. During this, the search was done by using the keywords such as; “COVID-19,” coronavirus disease 2019,” SARS-CoV-2,” “COVID,” “Covid-19,” “vaccine acceptance,” “vaccine hesitancy,” “vaccine refusal,” “vaccination,” “vaccine willingness,” “vaccine uptake” health care workers,” “professionals in health care,” “health-care professionals,” “healthcare workers,” “clinicians,” “health care professionals,” “health care worker,” “care providers,” “health professionals,” “health worker,” “primary care providers,” and “health care providers.” To integrate these keywords, Boolean operators “AND” and “OR” were used.

Eligibility criteria

All observational studies on COVID-19 vaccine acceptance among Ethiopian healthcare workers and papers published in English up to August 20,2022 were utilized as inclusion criteria. Publications in which the outcome variable was not clearly defined and assessed, as well as low-quality articles (see S2_file), were eliminated from this systematic review and meta-analysis.

Data extraction and quality appraisal

To organize search results and remove duplicated papers, all research collected from all databases were exported to EndNote citation manager software version X7. All studies were then exported to a Microsoft Excel spreadsheet. The search approach was used to retrieve study titles and abstracts. The studies that met the inclusion criteria through title or abstract screening were then subjected to a comprehensive full-text evaluation for eligibility and data extraction. The data were extracted by five independent authors (TM, TL, MS, AS, and TG) using a data extraction format prepared in a Microsoft Excel 2019 spreadsheet. The extracted data were as follows: the first author’s name, study year, study area, region, study design, sample size, data collection methods, response rate, and prevalence of vaccine acceptance (see S3_ file). The quality of all included articles was determined independently by five authors (TM, MS, TL, MS, and BT) by using Newcastle–Ottawa Scale (NOS) quality assessment criteria for cross-sectional studies (see S2_file). The modified NOS for cross-sectional studies was used to include articles with ≥5 out of 8 considered as a high-quality score²⁵ and any disagreements were resolved by discussion and consensus.

Outcome of interest

The primary outcome of this systematic review and meta-analysis was to estimate the level of COVID-19 vaccine acceptance among healthcare professionals in Ethiopia. COVID-19 vaccine acceptance among HCPs is the percentage of healthcare professionals who had intention to take the vaccine.

Statistical analysis

The extracted data on Microsoft Excel 2019 were exported to STATA version 11 software for meta-analysis. COVID-19 vaccine acceptance among HCPs in Ethiopia was pooled using a random effects model. The pooled prevalence of vaccine acceptance and it is 95% CI were presented using forest plots. For heterogeneity, inverse variance, subgroup analysis, and meta-regression were done. Inverse variance (I²) (for quantification) was used, and low, moderate, and high heterogeneity was defined as I² test statistics of <50, 50–75%, and >75%, respectively.²⁶ Subgroup analysis was also conducted using data collection methods and region. In addition, sensitivity analysis was done to see the effect of a single study on the overall result. Lastly, a funnel plot and the Egger's regression test at P-value <.05 were used to assess publication bias.

Ethics approval and consent to participate

Not applicable. This is because the study is a systematic review and meta-analysis. None of the data was collected from the people for this study. The study was performed by reviewing the recently published articles.

Result

Study screening

The initial literature search yielded a total of 5,971 articles through database searches such as African journals online, PubMed, Cochrane review, HINARI, Google Scholar, and Web of science. Of these, 1467 articles remained after removing duplication. After screenings of their titles and abstracts, there were 32 articles remaining whose full texts were assessed for eligibility. Finally, 11 studies were potentially eligible to undertake a systematic review (see Figure 1).

Figure 1. PRISMA flow diagram of included studies to estimate the pooled prevalence of COVID-19 vaccine acceptance among healthcare professionals in Ethiopia, 2022.

Study characteristics

A total of 11 articles with 5,981 study participants were included in this systematic review and meta-analysis. All of the studies used are cross-sectional surveys. Six out of 11 studies were conducted in 2021 and the rest by 2022. The sample size of the included studies ranged from 191 to 1,314, with an average sample size of 544 participants. In most of the samples, the age of respondents lies between 25 and 40 years (See Table 1). Among the included studies, COVID-19 vaccine acceptance ranged from 9% up to 74.8%.^{21,23,24,27–33}

Table 1. Study characteristics in the studies conducted on COVID-19 vaccine acceptance among healthcare professionals in Ethiopia, 2022.

Authors	Region	Sample size	Response rate	Study design	Data collection methods	Prevalence	Study quality
Tadesse et al.^Citation19	Oromia	191	90%	CS**	FFSA^3*	9	High
Alemu et al.^Citation20	Amhara	422	100%	CS	FFSA	45.3	High
Bekele et al.^Citation21	Oromia	319	100%	CS	FFSA	73	High
Bereket et al.^Citation29	Ethiopia	1,110	60%	CS	WBSA^4*	72.2	High
Daniel et al.^Citation22	Ethiopia	1,314	100%	CS	WBSA	74.8	High
Agazeh et al.^Citation26	Amhara	440	95%	CS	WBSA	54.1	High
Abiy et al.^Citation27	SNNP*	405	96%	CS	FFSA	48.4	High
Chilot et al.^Citation28	Amhara	319	67.87%	CS	WBSA	66.78	High
Metadel et al.^Citation25	Amhara	404	97%	CS	FFSA	64	High
Ahmed et al.^Citation30	Oromia	423	97%	CS	FFSA	53.1	High
Mohammed et al.^Citation31	Addis Ababa	634	97%	CS	FFSA	69.7	High

*SNNP = South nation nationality and people, **CS = cross-sectional, ³*FFSA = Face-to-face self-administered, ^4*WBSA = Web-based self-administered.

COVID-19 vaccine acceptance among healthcare professionals

From those 11 included studies, the estimated pooled prevalence of COVID-19 vaccine acceptance among healthcare professionals in Ethiopia with a random-effects model was 54.59% (95% CI: 42.49, 66.69) through a heterogeneity index (I²) of 99.1% (p < .001) (Figure 2).

Figure 2. Forest plot of the pooled prevalence of COVID-19 vaccine acceptance among healthcare professionals in Ethiopia, 2022.

Heterogeneity

Because of the high heterogeneity observed among selected studies (I-squared = 99.1, p < .001), subgroup analysis, meta-regression, and sensitivity analysis was implemented to clarify the source of heterogeneity. Subgroup analyses were performed using the data collection method and region. It revealed a slight variation due to data collection methods. As the result showed, the highest ((66.88%; 95% CI: 57.64,76.11), I² = 80.2%, p = .002) observed among studies that were collected by web-based self-administered questionnaire (Figure 3). The subgroup analysis result by region showed that there is no significant difference across the region. Despite this, there is generally no considerable difference between subgroup heterogeneity and overall heterogeneity exhibited in subgroup analysis, indicating that the heterogeneity was not associated with study region and data collection methods (Figure 4).

Figure 3. Sub-group analysis by data collection method of the pooled prevalence of COVID-19 vaccine acceptance among Ethiopian healthcare professionals, 2022.

Figure 4. Sub-group analysis by region of the pooled prevalence of COVID-19 vaccine acceptance among Ethiopian healthcare professionals, 2022.

Meta-regression was conducted to identify the source of heterogeneity using sample size and study year as a covariate. The P-value of both sample size and study year is non-significant. It means there is no effect of sample size difference and study year on heterogeneity between studies. In this systematic review and meta-analysis, sensitivity analysis was done using the random-effects model for the estimates of COVID-19 vaccine acceptance. The results of the sensitivity analysis suggested that there is no influential study as none of the points are estimated outside of the overall 95% confidence interval.

Publication bias

The presence of publication bias was checked by using Egger’s test, and a graphical funnel plot. The result of Egger’s test was not significant (p = .386) (Table 2). Also, a visual inspection of the funnel plot indicated a symmetrical distribution (Figure 5), suggesting the absence of publication bias for COVID-19 vaccine acceptance among healthcare professionals.

Figure 5. Funnel plot assessed for publication bias in the studies conducted on of COVID-19 vaccine acceptance among healthcare professionals in Ethiopia, 2022.

Table 2. Egger's test assessed for publication bias in the studies conducted on COVID-19 vaccine acceptance among healthcare professionals in Ethiopia, 2022.

Std Eff	Coef.	Std Err.	T	p > | t |	95%CI
Slope	4.677187	0.7731063	6.05	0.001	2.7854, 6.5689
Bias	_0.3873255	0.4144088	−0.93	0.386	_1.4013, 0.6266

Discussion

Although WHO and its partners are tirelessly working to distribute the COVID-19 vaccine, some countries are experiencing difficulties administering it.³⁴ The acceptance of COVID-19 vaccination by health professionals is crucial for successful virus control. Since HCPs are role models for the population and believe that they know a lot about health-related conditions. Compared to the general population, we expect a high acceptance of COVID-19 vaccine among HCPs. Therefore, they play a crucial role in instilling confidence in the general population regarding the vaccine.^11,18 Even though people’s willingness to receive vaccinations varies greatly within and between populations, the global willingness to receive a vaccine against COVID-19 is estimated at 66.01% (95% CI 60.76–70.89% I2 = 99.40%).³⁵ The global rate of coronavirus vaccine acceptance is quite low, especially in the Middle East, Russia, Africa, and several European countries. This represents a significant opposition to global efforts to contain the current COVID-19 pandemic.³⁶ In this review, we have critically reviewed the published papers that showed the acceptance of HCPs toward the COVID-19 vaccine in Ethiopia, which is among the major challenges the world is currently facing.

The estimated pooled prevalence of COVID-19 vaccine acceptance among healthcare professionals in Ethiopia with a random-effects model is 54.59% (95% CI: 42.49, 66.69) through a heterogeneity index (I²) of 99.1% (p < .00). The finding is in line with China’s healthcare providers’ acceptance rate at early invention of the vaccine³⁷ and COVID-19 vaccine acceptance of Central African, West African, and East African healthcare professionals.³⁸ This may be due to certain common barriers to the acceptance of the vaccine that seemed to be shared by HCPs in early invention of vaccine in China, middle- and low-income countries. These included fear of side effects of vaccines; short duration of the clinical trials; issues of vaccine safety, efficacy, and effectiveness; limited information on vaccines; and lack of social trust.³⁸ But it is much lower than among healthcare professionals in Israel (78.1%), in China after the invention of their own vaccine (86.2%), and among nurses in Italy (91.5%).^36,39,40 The finding was also lower than the vaccine acceptance rate of healthcare professionals in Southern Africa which was 90% (CI: 85%–96%).³⁸ The reason for this difference may be that in China the vaccine is developed by their own professionals. This may make them develop more trust and decide to take the vaccine, whereas in Italy, Israel, and South Africa, the morbidity and mortality as a result of COVID-19 is much higher.^41–43 This may have its own contribution to this significant difference. However, the finding is higher than the pooled estimated COVID-19 vaccine acceptance rate of health professionals in the Democratic Republic of Congo (27.70%).³⁹

In comparison with the general population, the result is in line with a rapid systematic review and meta-analysis of COVID-19 vaccine acceptance of the general population among low- and lower-middle-income countries result, which was 58.5% (95% CI: 46.9, 69.7, I² = 100%),⁴⁰ and among adults in Africa.⁴⁴ The result also has no difference with the vaccine acceptance level of populations of East Africa (60.2%, 95% CI: 52.8–67.3),⁴⁵ and with a pooled prevalence of COVID-19 vaccine acceptance among the general population of Ethiopia which was 56.02% (95% CI: 47.84, 64.20).⁴⁶ But the estimated value is lower than other studies of COVID-19 vaccine acceptance, most notably, among adults in Ecuador (97.0%), Malaysia (94.3%), Indonesia (93.3%), China (91.3%), and India (76.7%). This difference may be explained by low illness risk and low mortality in the country during the first two waves of the COVID-19 epidemic.⁴⁷ The hesitancy is mostly induced by the dissemination of misleading information through social media in Africa, specifically in Ethiopia.⁴⁸ Notably, low confidence in the vaccine, insufficient trust in the vaccine’s source and from the government, different conspiracy theories, religious beliefs, and possibly past vaccine hesitancy in the county are factors which are contributing to the low COVID-19 vaccination acceptance rate.^49–51 Lastly, it may be due to political instability in the country, Ethiopia, resulting in lower governmental concern for COVID-19 vaccination awareness creation. Even though this, the result of this study is higher than the vaccine acceptance rate among adults in Kuwait (23.6%), Jordan (28.4%),³⁶ and North Africa (37%).³⁸

Conclusion

The review shows generally low acceptance of the COVID-19 vaccine among healthcare professionals in Ethiopia. COVID-19 vaccine acceptance of HCPs acts as a valuable role model for the general public and, hence, it is very important to identify and address barriers to COVID-19 vaccine acceptance among them.

Limitation of the study

The presence of high heterogeneity between studies was the primary limitation of our meta-analysis. Even if subgroup analysis and meta-regression were used to deal with the heterogeneity, the exact source could not be determined. As a result, the interpretation of the result took these difficulties into account. Another limitation of this review was its geographic restriction to Ethiopia.

Abbreviations

Cl	=	Confidence interval
COVID-19	=	Coronavirus disease 2019
HCPs	=	Healthcare professionals
WHO	=	World Health Organization

Author contributions

Data curation: Tebabere Moltot, Tesfanesh Lemma. Formal analysis: Tebabere Moltot, Tesfanesh Lemma, Mulualem Silesh, Birhan Tsegaw. Investigation: Tebabere Moltot, Tesfanesh Lemma. Methodology: Tebabere Moltot, Tesfanesh Lemma, Mulualem Silesh, Birhan Tsegaw, Moges Sisay, Abayneh Shewangzaw. Software: Tebabere Moltot, Tesfanesh Lemma, Mulualem Silesh, Birhan Tsegaw, Moges Sisay, Temesgen Getaneh, Abayneh Shewangizaw. Supervision: Tebabere Moltot, Tesfanesh Lemma, Birhan Tsegaw, Temesgen Getaneh. Validation: Tebabere Moltot, Tesfanesh Lemma, Mulualem Silesh, Birhan Tsegaw, Moges Sisay, Temesgen Getaneh, Abayneh Shewangizaw. Visualization: Tebabere Moltot, Tesfanesh Lemma, Mulualem Silesh, Birhan Tsegaw, Temesgen Getaneh. Writing – original draft: Tebabere Moltot. Writing – review & editing: Tebabere Moltot and Tesfanesh Lemma

Acknowledgments

We would like to express our gratitude to all of the authors of the original articles included in this systematic review and meta-analysis.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

All relevant data are within the manuscript and its supporting information files.

Additional information

Funding

The author(s) reported that there is no funding associated with the work featured in this article.