|Year : 2022 | Volume
| Issue : 1 | Page : 42-49
Knowledge, beliefs, barriers, acceptance, and encouragement cues associated with COVID-19 vaccination among health-care workers in India
Varchasvi Mudgal, Vijay Niranjan, Pali Rastogi, Priyash Jain
Department of Psychiatry, MGM Medical College, Indore, Madhya Pradesh, India
|Date of Submission||10-Sep-2021|
|Date of Decision||14-Dec-2021|
|Date of Acceptance||16-Dec-2021|
|Date of Web Publication||23-Jun-2022|
Dr. Priyash Jain
Department of Psychiatry, MGM Medical College, Indore - 452 001, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Background and Aim: The coronavirus disease 2019 (COVID-19) is a viral pandemic that has infected millions of people that has caused the loss of human lives on an unprecedented scale. India being the second-most populous country in the world has been severely impacted by COVID-19. India began its vaccination drive on 16th January 2021 with a huge burden of 1.3 billion people to be vaccinated. Various factors play their role to predict the success or failure of a vaccination drive. The study was aimed to assess knowledge, belief, barriers, and acceptance of the COVID-19 vaccine among healthcare workers of a tertiary care centre. Materials and Methods: This cross-sectional study was done on healthcare workers (HCW) in February 2021. 120 HCWs participated in the study after providing their consent. Data were collected using a semi-structured proforma which included basic sociodemographic details, a questionnaire about acceptance, knowledge, beliefs, and barriers against the COVID-19 vaccine. Results: The mean age of the sample was found to be 36.5 years. Average knowledge, calculated by assessing the mean responses to all the questions pertaining to knowledge, was found to be 78%, while an average of 73.5% had positive beliefs regarding the vaccine for COVID-19. Concern over side effects and doubts over vaccine efficacy turned out to be the greatest barriers contributing to vaccine hesitancy. Acceptance rates of 87.4% were obtained across all the samples. Conclusion: Physician recommendation, acceptance by peers or family, and more studies to prove vaccine efficacy was widely acceptable cues to encourage vaccination. The study with its key findings could be a helpful aid in policymaking to boost India's vaccination drive.
Keywords: Acceptance, barrier, belief, coronavirus disease 2019, knowledge, vaccine
|How to cite this article:|
Mudgal V, Niranjan V, Rastogi P, Jain P. Knowledge, beliefs, barriers, acceptance, and encouragement cues associated with COVID-19 vaccination among health-care workers in India. Arch Med Health Sci 2022;10:42-9
|How to cite this URL:|
Mudgal V, Niranjan V, Rastogi P, Jain P. Knowledge, beliefs, barriers, acceptance, and encouragement cues associated with COVID-19 vaccination among health-care workers in India. Arch Med Health Sci [serial online] 2022 [cited 2022 Oct 3];10:42-9. Available from: https://www.amhsjournal.org/text.asp?2022/10/1/42/347955
| Introduction|| |
The coronavirus disease 2019 (COVID-19) is a viral pandemic that gripped the world infecting millions of people globally and causing thousands of deaths on daily basis. India, the second-most populous country and the largest democracy in the world, has been impacted by COVID-19 on an unforeseen scale. Various response strategies, including lockdown measures and public awareness measures, were springing into action immediately after COVID-19 spread to the nation. India is second in total COVID cases only to the USA with 10,916,589 cases and 155,732 deaths (as of February 15, 2021).
Even in presence of social distancing, strict government tracking, and diligent work by the health care sector, there is a huge burden of the disease as per the Ministry of Family Health and Welfare department. With India tackling an already existing burden of health-care gap and economic disruption COVID-19 has had a severe impact on the country. Since the spread of the disease, there were global efforts to create a successful vaccine to tackle the COVID-19 pandemic. As of January 16, 2021, India started its phase-wise national vaccination program against the COVID-19 pandemic for the 1.3 billion population and has administered about 8,285,295 doses to various strata of the population (as of February 15, 2021). There is much misinformation about COVID-19 and its vaccine prevailing in the general population and healthcare sector even after the rollout despite heavy campaigning by government agencies for the vaccine.
The public acceptance of a new vaccine for the ongoing COVID-19 pandemic which is being developed with a short period of testing remains uncertain. Thus, vaccine hesitancy may become an important hurdle to overcome. Vaccine hesitancy is construed as a significant concern towards public safety and mass vaccination. In a nation of over 1.3 billion extensive vaccine coverage is needed to curb the exponential epidemic growth and flatten the COVID-19 curve. Vaccine hesitancy is not exclusive to just an individual rather it affects on a much greater scale involving the community, state, and country in its vicious claws and ultimately leading to a difficult path towards herd immunity. There are certain beliefs and barriers regarding vaccination among the general population. Acceptance and community delivery of the vaccine is a multifactorial construct that varies as per current chronological trends, local cultures, religious beliefs, the behavior of the people, and geography.
Factors that determine the acceptance of vaccines include the severity of the disease, previous vaccination history, lack of belief in health care services, route of administration of a vaccine, economic and educational status of the individuals, recommendations from doctors, and cost of the vaccine.
India has struggled with previous vaccination drives including polio, H1N1 virus, Hepatitis B, etc., The Government of India (GOI) has begun the process of vaccination with the frontline healthcare workers (HCW) but there is a cloud of misconception there as well. Hence, there is a need to assess the current knowledge beliefs and attitudes of the healthcare and associated workers and secondarily to educate all Indians about the efficacy and tolerability of vaccines with clarifying the side effects of the vaccine. Vaccination programs are only successful when there are high rates of acceptance and coverage. The purpose of our study is to understand variables including the sociodemographic variables, economic variables, vaccine acceptance beliefs, and barriers that divert the participants against vaccination.
| Materials and Methods|| |
The study has a cross-sectional design and was conducted in a tertiary care center to understand the patterns of knowledge, beliefs, and barriers toward COVID-19 vaccination among various strata of frontline workers and associated staff. Data were collected using a semi-structured proforma which included basic sociodemographic details, a questionnaire about acceptance, knowledge, beliefs, and barriers against the COVID-19 vaccine which was based on a previous study with some modifications. Institutional ethics committee approval was taken. A pilot survey was done to validate the correctness of the questionnaire. The questionnaire was prepared in the English language. It was disseminated through print and electronic format that was distributed with the help of E-mail and online social networking platforms in February 2021. The study duration was 1 month, and convenient sampling was used for the recruitment of samples. The study samples included four groups doctors, nursing staff, technical staff, and helping staff. Thirty samples from each group were recruited after obtaining valid consent.
| Results|| |
A total of 120 participants were recruited. [Table 1] shows that the mean age of the participants was 36.5 years with most participants being in the 32 − 41 years' age group. More than half the participants (54.2%) were males, more than two-third (77.5%) were married, and the majority had attained university and above education (57.5%). As per inclusion criteria doctors, nursing staff, technical staff and helping staff each made up 25% of the sample population.
In [Table 2] adequate knowledge refers to the proportion of participants having correct knowledge to a particular question while the proportion of participants having incorrect knowledge or those having no awareness were termed to be having inadequate knowledge. The assessment of knowledge regarding COVID-19 vaccine as shown in [Table 2] revealed that 100% doctors, 100% nursing staff, 96.7% technical, and 93.3% helping staff were aware of the presence of vaccine in the nation. 83.3% doctors, 76.7% nursing staff while 46.7% technical and 40% helping staff were correctly aware of the types of COVID vaccine availability. Hundred percent doctors and 93.3% nursing staff had correct knowledge about the route of the vaccine while about 73.3% of technical and 63.3% of helping staff knew the correct route of vaccination. On the assessment of the correct schedule of vaccination, it was seen that 96.7% doctors and 90% nursing staff were correctly aware while 73.3% of helping and 63.3% of technical staff were right regarding the schedule of vaccination. On inquiring about the need to take safety precautions between the administration of doses 93.3% doctors, 76.7% of nursing staff, 56.7% of technical, and 53.3% helping staff gave the correct response. Thus, about 78% of the participants had adequate knowledge regarding COVID-19 vaccination which was obtained by averaging out all responses pertaining to knowledge.
Assessment of beliefs regarding the vaccine was undertaken which is displayed in [Table 3]. 53.3% doctors, 46.7% of nursing staff, 23.3% technical staff (23.3%), and 33.3% helping staff believed that there is still a risk of contracting COVID-19 despite complete vaccination schedule. Regarding the safety of the vaccine, 86.7% doctors and 83.3% nursing staff were convinced while 30% technical and 36.7% helping staff had doubts regarding the safety of the vaccine. Assessment of beliefs regarding efficacy of the vaccine demonstrated that 93.3% doctors and 80% nursing staff believed the vaccine to be efficacious while 33.3% technical staff and 26.6% of helping staff lacked the confidence regarding the efficacy of the vaccine. About 30% of nursing staff (30%), 33.3% technical staff, and 36.7% helping staff believed that currently vaccination is not the best way to avoid COVID-19 complications while 80% doctors believed otherwise. In the context of perceived outcome after vaccination in terms of risk and benefit, the majority of the participants (doctors 90%, nursing staff 83.3%, technical staff 80%, helping staff 80%) in all groups believed that the COVID vaccine would lead to more benefits than risk. On averaging out the responses regarding beliefs of the participants it turned out that 73.5% of them had positive beliefs regarding vaccination.
[Table 4] shows the barriers associated with acceptance of COVID-19 vaccination. For the helping staff washing of hands and use of mask and gloves (23.3%), side effects of the vaccine (20%), taking the right measures against COVID (16.7%), and COVID-19 being a conspiracy theory (16.7%) were significant barriers. In technical staff, the following acted as barriers-side effects of the vaccine (60%), doubts regarding efficacy (16.7%), and adequate precautionary measures being used (16.7%). Nursing staff had barrier patterns similar to the technical staff-side effects of the vaccine (60%), doubts regarding efficacy (20%), and adequate precautionary measures being used (20%). For doctors concern over side effects (63.3%) was the biggest barrier while doubt over vaccine's efficacy (33,3%) was another big barrier.
The majority of all the participants had a high acceptance rate for COVID-19 vaccine administration (doctors 93.3%, helping staff 90%, and technical and nursing staff 83.3%). The average acceptance rate across all samples was found to be 87.4%.
Evaluation of cues to encouragement in the samples revealed that physician recommendation (59.3%), vaccination by family/friends (52.5%), and more studies regarding safety and efficacy of the vaccine (51.6%) were the top cues for facilitating vaccination. For the doctor group, the presence of more reliable studies regarding vaccination safety and efficacy (70%) came out to be the top cue. For the nursing staff, mandatory vaccination by their employer (60%) seemed to be the top cue to encourage vaccination. For the technical staff, recommendation by their physician (86.7%) was the top cue toward encouragement for vaccination. The helping staff reported physician recommendation (83.3%), compulsory vaccination by the government (70%) to be the top cue for encouragement for vaccination.
| Discussion|| |
This study assesses the acceptance, knowledge, belief, and barrier toward the COVID-19 vaccine in India. In our study, the mean age was found to be 36.5 years which is comparable to the mean age reported in similar studies., The mean age in our study was lower than the mean age found in the studies by Mytton et al. and Pelullo et al. which had a mean age of more than 40 years., Our study had a male preponderance which agrees with the study by Qadah while the study by Mbachu et al. reported it to be otherwise. This was again an expected result from an institute belonging to a developing country where males still make the majority of the workforce., Most of the participants were married which was again similar to the findings by Mbachu et al., Qattan et al., Qadah,, [Table 1].
In our study, 78% of the participants had adequate knowledge. The knowledge levels were influenced by the category of HCW and other sociodemographic factors such as age and education. Doctors had the highest knowledge followed by nursing staff. Helping staff was placed at the lowest rung. Different studies have used different tools to assess knowledge, thus we are comparing studies that have assessed knowledge in comparable domains. The knowledge levels reported in our study are lower compared to the study by Zhang et al. who found knowledge levels to be 89% among Chinese HCW, Qadah in Saudi Arabia reported 88%. Mbachu et al.(Nigeria) reported knowledge levels similar to our study at 81.3%, while in a study by Ghimire et al.(Nepal) knowledge levels reported were very low at 45.7%,,, [Table 2].
We studied the beliefs of our participants regarding COVID-19 vaccination and positive belief regarding vaccination turned out to be 73.5%. The high percentage of positive beliefs could be linked to the fact that our sample consisted primarily of HCW and associated staff who have greater exposure to COVID-19 and related activities and higher knowledge regarding COVID-19 vaccination, secondarily this can be attributed to the response bias of the sample who are under employment by the government. Public beliefs regarding a vaccine are one of the strongest determinants of vaccine acceptance. Positive beliefs regarding vaccination reduce vaccine hesitancy and improve its acceptance among the public. Finally, although we found about three-quarters of the participants (HCW) held positive beliefs, it does not necessarily imply that such rates will percolate through to the general public, where understanding about the disease and vaccine is quite different. This was evidenced in a study by Magadmi and Kamel which reported positive beliefs to be a meagre 32.9% in the general population. Previous vaccination trials have established that negative beliefs regarding the efficacy and safety of vaccines were linked to reduced intention to get vaccinated.,, As for the misinformation regarding covid vaccination, the doctors had correct belief because the orientation programs for covid vaccine incorporated doctors but other health-care staff were not as involved and were not informed about vaccine efficacy and safety [Table 3].
Assessment of barriers regarding COVID-19 vaccination revealed that concern over side effects (50.82%) and concern over vaccine efficacy (19.17%) were the biggest barriers regarding COVID-19 vaccination. This finding is similar to that of a study by Magadmi and Kamel in which the greatest barriers toward vaccination were also “concerns over its side effects” (80%) and lack of overconfidence in the efficacy of vaccine (25%). In a study by Sharun et al. 64% of the participants expressed similar concerns over the vaccine's side effects. In another study by Seale et al., about 45% of the participants expressed concern over the side effects of the H1N1 vaccine alluding to the rush through the process of vaccine development owing to the pandemic situation [Table 4].
Our study indicates that acceptance for the COVID-19 vaccines to be 87.4% which is similar to a study by Mehta and Dhaliwal which found vaccine acceptance to be 84.1%. In various studies high acceptance rates have been demonstrated like 76% by Fu et al. in China, 64.2% by Askarian et al., in the Iranian population, 50.5% by Qattan et al. in Saudi Arabia amongst HCWs. In a systematic review by Sallam who compared acceptance rates in various studies, they found acceptance rates to be highest in Israel at 78% which is still low compared to our study. In a study by Kabamba et al. in the Democratic Republic of Congo acceptance was found to be 27.7% which they attributed to misinformation about vaccines and false information circulating in social media [Table 5].
The high acceptance rate for the vaccine is explainable as the vaccine drive in India was started after gaining experience from multiple trials and vaccine coverage elsewhere in the world. Secondly, the World Health Organization and the GOI endorsed the safety and efficacy of the vaccine which boosted the acceptance amongst HCWs. Identified as one of the most exposed populations, HCWs had no other viable alternative for the prevention of COVID-19 and it provided a ray of hope under such gloomy circumstances. Lastly, the acceptance could be attributed to the cost of vaccination being borne by GOI which can be considered an encouragement cue. Along with such positive factors multiple measures were taken in India to prevent the malicious spread of misinformation along with print and electronic media representing a positive outlook.
In our study, cues to encourage vaccination that had the most positive responses were-physician recommendation (59.3%), vaccination by family/friends (52.5%), and more studies regarding the safety and efficacy of the vaccine (51.6%). This finding is similar to other published studies. In a study by Motta et al., they found a campaign focussing on personal risks and potential collective public health were effective encouragement cues to get a COVID vaccine. However, in India, physician and family recommendations along with a strongly backed scientific evidence base of vaccine efficacy were effective methods to overcome vaccine hesitancy [Table 6].
| Conclusion|| |
Our study revealed that the HCW population had a high acceptance rate with adequate knowledge, a positive attitude, and a belief structure. Factors to overcoming hesitancy include a strong physician backing with family and peer acceptance. To our knowledge, this is the first such study in India and can be helpful in the formulation and implementation of various COVID-19 vaccination policies and drives. The limitations of the study include modest sample size from a single centre, the sample population belonging to a specific high-risk group of HCWs, disparate distribution of demographic relates, risk of response bias owing to participants being government employed, and lastly, lack of availability of viable alternatives and the highly contagious nature and potential lethality of COVID-19 may contribute to higher overall acceptance.
Future studies with greater sample sizes and diverse sample populations must be replicated in the general population to correctly gauge the knowledge, beliefs, and barriers associated with COVID-19 vaccination. At present, there is a significant lack of correct knowledge even among HCW which does not bode well for the general population. Being a nation of more than a billion despite even with heavy vaccine coverage statistically reaching a majority coverage still leaves millions vulnerable, who can be at risk themselves, act as carriers or host for newer mutant strains. Similar to other densely populated countries India requires uniform, cost-effective evidence-based, and mass-acceptable vaccination strategies. There is a need to fill this gap by using electronic media and print media to involve the masses. Better knowledge will translate into better beliefs and acceptance of the COVID-19 vaccine and at the same time diminish barriers related to the COVID-19 vaccination.
After analysis of our results and review of existing literature, there are a few recommendations for the policymakers which could be helpful for handling the menace of COVID-19. Firstly, as India stands at 62nd position amongst 107 countries as per global multidimensional poverty index 2020, and a significant proportion lives below the poverty line, a free vaccination policy by the government could help in greater acceptability and deeper reach into the public. Second, in our study, we found that endorsement of vaccination by the physician was a helpful cue to encourage vaccination, thus there is a need for sensitization of physicians, family doctors, and other HCWs to promote and strongly endorse vaccination to the public. Thirdly other than politicians and administration we need to rope in people from various sects of the country such as celebrities, local stakeholders, village heads, religious and spiritual leaders, teachers, social workers, sportspersons, etc., to come forward and help the vaccine drive. Other recommendations include greater participation of media, stringent laws to curb the spread of misinformation, and the use of positive incentives to get vaccinated like rebates in utility bills, food distribution. To improve the information and awareness regarding vaccination healthcare staff along with doctors should be more actively recruited for future vaccination drives and policymaking. Finally, as evidenced by the ongoing trends of COVID-19 progression further mutations and spread of the disease cannot be ruled out hence we need to develop adequate infrastructure for self-reliance in the production and distribution of vaccines.
We would like to acknowledge and extend our gratitude to all the participants for their patience and cooperation. We would also like to acknowledge the help provided by the residents and faculty members of the Department of Psychiatry. Finally, we express deep gratitude to all the authors cited for their valuable help in the current work.
Financial support and sponsorship
We certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on us or on any organization with which we are associated and, if applicable, we certify that all financial and material support for this research and work are clearly identified in the title page of the manuscript.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]