Uptake of the COVID-19 Vaccination and Associated Factors Among Health Care Providers in Addis Ababa, Ethiopia

Introduction

Background Review

COVID-19 is a communicable severe acute respiratory syndrome caused by SARS-COV-2 viruses, originally detected in December 2019 in Wuhan province in China. Globally, more than 579 million people have been infected, and 6.4 million have died from the virus. Similarly, in Ethiopia, 492 thousand people have been infected and 7.5 thousand have died from the virus as of August 3, 2022.¹ Even though non-pharmaceutical prevention methods have been in place, COVID-19 infection and transmission remain unchanged.² Hence, effective vaccines against coronavirus have been developed and approved to be used as an effective preventive method since August 23, 2021. Accordingly, 12 billion doses of vaccines had been administered globally as of August 3, 2022.^1,2 Ethiopia administered the first dose of vaccine at Yeka Kotebe hospital for HCWs to mark the beginning of vaccination on March 13, 2021.^3,4 So far, more than 52.4 million doses of COVID-19 vaccines have been administered in the country.³

HCWs are the most exposed segment of the population to coronavirus disease due to their occupational exposure. Furthermore, ensuring vaccination among health-care providers enhances vaccine uptake among the general population^2,5,6. In order to develop herd immunity, high coverage of vaccination should be achieved.^7–9 However, COVID-19 vaccine uptake among health professionals is lower, as evident by studies in the United States, United Kingdom, Vietnam, and Saudi Arabia that revealed low acceptance.^10–14 A study conducted in south western Ethiopia among health-care providers showed low intention to accept the COVID vaccine.¹⁰

However, despite the provision of priority for HCWS, addressing all barriers to vaccine uptake among HCWs, including socio-demographic factors, occupational factors, sources of information, and vaccine hesitancy, is important for the government and policymakers.^4,8,15,16

Previous studies in Ethiopia assessed willingness and intention to get vaccinated when vaccines are available.¹⁶ However, this study aims to assess real-time factors associated with COVID-19 vaccine uptake among HCWs.^4,16 The findings will help to adopt healthy behaviors towards vaccine acceptance and provide insight for decision-makers and programmers.

Statement of the Problem

Vaccination is critical to tackling the spread of coronavirus disease. However, herd immunity is only achieved if the coverage is sufficiently high.^7–9,14,17 However, despite the availability of vaccines, the acceptance rate among health-care workers is not the same.^10,12,13 A study conducted in Jordan found that the public’s acceptance of the COVID-19 vaccine was only slightly above average.⁷ Different studies conducted in various countries revealed vaccine hesitancy is the major factor in low vaccine acceptance, as has been proven in HPV vaccine and flu vaccine acceptance.^9,18 Most countries reported that less than half of the target population received the vaccine. Hence, vaccine hesitancy remained pervasive in the general public and among health-care providers across the world.^5,10,19 As a result, public health authorities must take systematic measures to lower vaccine hesitancy levels and increase vaccine acceptance.^13,20 Even though health-care providers are the most vulnerable segments of the population, they have low acceptance of the COVID-19 vaccine, as shown by studies conducted in the United States, the United Kingdom, Vietnam, and Saudi Arabia.^6,21–23 A further study conducted in south-western Ethiopia among health professionals revealed low intention to accept the COVID vaccine. Health professionals should be given priority due to the high risk of exposure and as an example for the general population; therefore, it is crucial to take into account HCW attitudes towards the COVID-19 vaccine.^7,16,24 Addressing barriers to vaccine uptake among health-care workers is crucial for the government and policymakers, as patients rely on health-care workers as sources of information and behavior. Low vaccine uptake is often due to misunderstandings and false beliefs about vaccine effectiveness.⁴ This study aims to assess real-time factors associated with COVID-19 vaccine uptake among health-care workers, which may vary after the program is established.

Methods

Study Setting and Period

The study area is located in Addis Ababa, the capital of Ethiopia, which has eleven sub-cities and has been estimated to have 2,739,551 residents as of the 2007 census. According to data from the Addis Ababa Health Bureau, the Addis Ababa City Administration has 6 hospitals and 101 public health centers. The city administration has 13,541 total different including 575 physicians, 1034 pharmacists, 4829 Nurses, 2273 health officers, 983 laboratory technicians, 1125 midwifery, 181 HIT, 56 psychiatrist and 2489 other professionals according to the information found from Addis Ababa Health Bureau. The data was collected from June 10, 2022 to July 10, 2022. The study was conducted in four sub-cities randomly chosen based on lottery methods. Addis-Ketema, Gullele, Lideta, and Yeka are the selected sub-cities. There are 42 health centers in total, with 10, 10, 8, and 14 health centers in each sub-city, correspondingly.

Study Design

Facility-based cross-sectional study was conducted to assess uptake of COVID-19 vaccine and associated factors among health-care providers in Addis Ababa.

Source Population

Health professionals who were full-time employees in public health centers located in Addis Ababa city administration.

Study Population

The study population for health facility-based survey was all clinicians who provide direct or indirect care to patients from chosen health facilities.

Study Objectives

This study had two specific objectives. The first objective was to determine the level of uptake of COVID-19 vaccine among health-care providers in Addis Ababa and the second objective was to identify factors associated with uptake of COVID-19 vaccine among health-care providers in Addis Ababa.

Sample Size Determination

Sample size was determined using two population proportions formula, Using 58 proportion of vaccine uptake level from the online study conducted among health care in Ethiopia.²⁵

Using the prevalence of uptake among those who perceived not healthy family = 21.3% and prevalence of uptake among those who perceived healthy family = 78.7%

The final sample would consist of 512 participants who were chosen by simple random sampling after adding a 5% non-response rate. A total of 21 health centers, representing 50% of the 42 health centers in the four sub-cities of Gualle, Lideta, Addis-Ketema, and Yeka, were chosen by multi-stage sampling.

Sampling Technique

Multistage sampling method was used to select candidate health facilities and a simple random sampling technique was employed to select health-care providers’ the final study unit.

Sampling Procedure

Four sub-cities were randomly chosen using the lottery method from a total of 11 sub-cities in Addis Ababa for this study, and they were Gulalle, Lideta, Addis-Kete ma, and Yeka. These sub-cities had a combined 42 health centers. According to the AACRHB, each health center was anticipated to provide care for about 100,000 persons within its designated catchment area. Then, from among these 42 health centers, half were chosen at random; as a result, 21 health centers were chosen through a lottery system. The sample size was allocated proportional to each sub-city, then to the respective health facility proportionally. Within each health center, health professionals included in the study were; Doctors, Midwives, Nurses, Laboratory technicians, Health officers, Pharmaceutical professionals, psychiatrist, midwives and the sample size allocated to the facilities were randomly selected from the list found from human resources of respective health centers (Figure 1).

Figure 1 Schematic presentation showing sampling procedure and technique of public health centers; Addis Ababa, Ethiopia, 2022.

Inclusion and Exclusion Criteria

Health-care workers who were greater than 18 years of age and who worked for six or more months in public health centers before study commenced were included.

Exclusion Criteria

Health-care workers who got severely ill and cannot provide responses to the questionnaire during data collection.

Data Collection Method

The English version of the questionnaire was translated into Amharic, and then, for consistency’s sake, it was translated back into English by other experts. Data was collected with a pretested interviewer-administered structured Amharic version questionnaire. Data will be collected by questionnaire developed from relevant literatures.^7,26–29 Questionnaires that were pre-tested in health-care facilities other than the selected study setting internal consistency were checked through Cronbach alpha for Likert scale items, which was 0.752.

Data Collection Tool

Standardized structured questionnaires were used to collect relevant information. The survey consists of the following sections: part I has three sections; the first section includes the Sociodemographic characteristics (age, sex, religion, level of education, marital status, occupation, presence of comorbidities and profession). The second section assesses past COVID-19 infection and vaccination history (previous infection, family history, types of COVID-19 vaccines, Influence of others, and source information of COVID-19 vaccine). The third section assesses risk-perception of COVID-19 and vaccines (a perceived concern towards COVID −19 infection, attitude towards covid-19 vaccines, and mistrust in health system). Attitude towards covid-19 vaccines Contains questions with a 5-point Likert scale (1 to 5) where 1 is least score and 5 is the largest score then based on the mean score of the total item it will be dichotomized as positive or negative attitude towards the vaccine. Those above the mean will be considered as having a positive attitude and those with scores below the mean will be categorized as having a negative attitude towards the vaccine.

Data Collection Procedure

Interviewer-administered structured questionnaire was provided for the participants and their responses were documented by the interviewer.

Data Quality Assurance

The survey was written in English, translated into Amharic, and returned to English for consistency. Seven data collectors and one supervisor received training to ensure completeness, accuracy, and consistency. Data quality was ensured through supervision by the lead investigator, training on sample techniques, and pre-testing with a 5% sample from other health facilities. Inconsistent and incomplete data were handled appropriately.

Operational Definitions

Covid-19 vaccine uptake is defined as individual respondents who had already at least received a single dose of any type of COVID-19 vaccine.

Previous exposure: participant who had laboratory-confirmed covid-19 infection or had contact with laboratory-confirmed covid-19 infected person.

Perceived concerns: HCWs perception of the risk of becoming infected from COVID-19 themselves or their close family, due to their roles in the health facility.

Attitude towards vaccines: Perceived confidence level in a vaccine safety and effectiveness.

Mistrust in the health system: Belief of HCWs in science and decision of ministry of the health in favour of their benefits.

Permanent health-care worker: Health-care workers who served six months or more in the facility as direct or indirect service for clients.

Health-care facilities: Health-care service providing government health centers.

Data Processing

From open data kit version 2022.2.1, data was exported to excel, and from there, it was exported to SPSS for analysis. Data were cleaned for outliers and missing value.

Analysis

While means and standard deviation were used to summarize continuous variables, percentages, frequencies, and proportions were used to summarize categorical variables. Binary logistic regression was carried out to assess factors associated with uptake of COVID-19 vaccine expressed by adjusted odds ratio (AOR) along with its respective 95% (CI).

A five-point Likert scale was used to assess the attitude towards covid-19 vaccine which has a scoring system from strongly disagree which were given 1 for those who have not concerned about covid-19 vaccine safety and efficacy to strongly agree were given 5 for those who have concerned about the COVID-19 vaccine safety and efficacy. Attitude towards vaccine was measured using items about concerns about the safety and efficacy of covid-19 vaccine and then the overall mean was calculated and assessed across the gender and professions. Concerns about Covid-19 vaccine were given a score of 1, those who have one concern 1, and two concern 2, and a maximum of score 3.

All assumptions for binary logistic regression including no category containing less than 5 expected value, multicollinearity was considered for variables included in the equation with variance inflation factor (VIF) greater than 10. Linearity of continuous variables were checked against their log odds. Outliers of continuous variables were checked using Mahalanobis distance significance for at 0.001 and there were no outliers figured out. Independent variables with P-value <0.25 were considered in multivariate logistic regression. The Hosmer and Lemeshow test with a p-value of >0.05 was used to evaluate the model’s goodness. Statistical significance was assigned to variables with p values less than 0.05.

Ethical Approval

Ethical approval and clearance letter was obtained from Addis Ababa University and Addis Ababa health bureau with reference number of SPH/321/14. Letter of permission was secured from AACHB and selected respective sub-city health offices.

Results

Socio-Demographic Characteristics of Respondents

The total number of participants was 473 out of a possible 512 health-care providers, which resulted in a response rate of 92.4%. Among them, 34.5% were male and 65.5% were female. The mean age of the participants was about 34.87 years with a standard deviation of 7.21. More than one-third of respondents, 43.8%, were aged between (27–35) years old. Most of the respondents were nurses, 31.9%, followed by health officers, 15 0.4%. Of all of the total respondents, 34.1% were married, and 39.1% were Orthodox religious followers. More than half, 53.3% of respondents had a diploma, 37.2% of respondents earned less than 6193 (USD 120) and 32 (6.8%) of respondents earned more than 9057 Ethiopian birrs monthly. Nearly 42% of the health-care providers were responsible for direct medical provision (Table 1).

Table 1 Socio-Demographic Factors Distribution Among Health-Care Providers in Addis Ababa Ethiopia 2022

Previous COVID Exposure

The study found that 27% of health-care professionals had contact with COVID-19-positive patients, and 16% had comorbidities. Over 78.6% had been tested for COVID-19 and 16.3% were infected. Most professionals trusted the science of COVID-19 vaccine development and the ministry of health’s safety. 27.4% of health-care providers were concerned about COVID-19 due to their roles in the health facility, while 52.9% were concerned about the potential risk to their family (Table 2).

Table 2 Health-Care Provider’s Previous Exposure Among Health Workers in Addis Ababa 2022

Sources of Information

Most health-care professionals (36.32%) acquired their information about COVID-19 vaccination from television, while 30.51% came from social media (Telegram, Facebook, Google, WhatsApp). The majority of health-care professionals (20.46%) and patients (9.52%) rely on their peers for information (Figure 2).

Figure 2 Source of information for covid-19 vaccination uptake for Health care providers among health care providers in Addis Ababa in Ethiopia, 2022.

Vaccine Concerns

The overall vaccination concerns were relatively low. However, concerns with regard to attitude towards covid-19 vaccines are prevalent. Most health-care providers believe that in general COVID19 vaccines are important for their health (72.8%) and (63.7%) for the health of their community. Most of HCP believe covid-19 vaccines are effective (54.1%) and safe (57.5%). Most health-care providers (64.9%) were confident regarding the decisions made on COVID-19 vaccination by political leaders is in the best interest of the community. A majority of health-care providers (65.8%) did not believe. The vaccination sites are too far for them. In addition, more than two-third (65.5%) of HCP did not consider the process of getting vaccinated is stressful. However, 29.2% health-care providers believe the process of getting vaccinated is stressful (Figure 3).

Figure 3 Attitude of health care providers towards covid-19 vaccine Addis Ababa, Ethiopia, 2022.

Multivariate Logistic Regression

After bi-variate logistic regression was done variables with the p-value <0.25 were taken into multivariable logistic regression analysis. A multi-variable logistic regression analysis was done for socio-demographic factors; gender, age, marital status, educational status and monthly salary were significantly associated with a COVID-19 vaccine uptake. Being female was associated significantly with COVID-19 vaccine uptake and females were 51% less likely compared to male professionals [AOR (95% C.I): 0.486 (0.258–0.916)]. Health-care Workers whose age was between (36–45) years were nearly three times more likely to accept covid-19 vaccine as compared to those below 25 years AOR: (2.7 (95% C.I): (1.03–7.613)]. Married health-care providers were two times more likely to receive COVID-19 vaccine compared to unmarried health-care provider [AOR: 2.114 (95% C.I: 1.068−4.181)]. Educational status was significantly associated to COVID-19 vaccine uptake and professionals who had BSc. Degree were twice more likely to receive covid-19 vaccine as compared to HCPs who had Diploma [AOR: 2.118 (95% C.I: 1.067 4.203)]. HCWs who had monthly income between 6194 and 9056 ETB were significantly associated with COVID-19 vaccine uptake 2.6 times more likely to receive vaccine as compared to workers paid below 6194 [AOR: 2.623 (95% C.I): 1.398−4.923)]. HCPs who were unsure of their contact history were 66% less likely to take covid-19 vaccine compared to their counterparts [AOR: 0.340 (95% C.I): 156–0.741)]. HCPs who got vaccination information from their peers were four times more likely to receive covid-19 vaccine [AOR: 4.48 (95% C.I): 1.77–11.284] compared to others source. HCWs with higher risk perception were 7 times more likely to take vaccines compared to their counterparts [AOR: 7.455 (95% C.I): 4.041–13.754)]. Variables such as being tested for covid-19, family size and recommendation of vaccination by others were non-significant (Table 3).

Table 3 Multivariable Logistic Regression to Determine Associated Socio-Demographic Factors Among Health-Care Providers in Addis Ababa, Ethiopia, 2022

Discussion

In the current study vaccine, uptake among health-care providers was 75.8%. This finding was higher compared to the study conducted a year ago in three cities of Ethiopia among health workers to estimate future vaccine uptake against SARS-CoV-2 when the vaccine is available, which was revealed (72.2%).^30,31 Similarly, this finding was higher than an online study conducted among health workers in Ethiopia to assess vaccination uptake, which showed 62.1%.²⁵ This might be due to these studies being conducted early when vaccination was not launched widely and the late arrival of additional doses of COVID-19 vaccines. However, this finding was lower than the outcome of the study conducted in Greece and Turkey^18,32. This discrepancy might be due to the difference in socio-demographic characteristics, risk perception, and vaccine hesitancy.

The most important factors identified as predictors of COVID-19 vaccine uptake by this study were gender, advanced age, marital status, educational status, monthly salary, previous contact with COVID-19-infected patients, trust in the science to develop a vaccine, trust in the ministry of health to ensure COVID-19 vaccine safety and effectiveness, perceived concerns of COVID-19 infection and source of information for COVID-19 vaccination (Table 3).

This study identified that female professionals were 51% less likely to take the COVID-19 vaccine [AOR=0.486 [CI; 0.258–0.916, P-value=0.026] compared to their counterparts.³⁰ This result was congruent with a similar study conducted among health-care workers in Ethiopia, America, and UK which revealed female health providers were less likely to take the COVID-19 vaccine.^25,28,33 This might be due to pregnancy or being a lactating mother and fear of vaccine-induced COVID-19 infection transmission to their baby. Moreover, this might be related to the fear of receiving an injection shot.

The rate of COVID-19 vaccine uptake was higher among health professionals aged (36–45) years old compared to younger professionals (18–26) years [AOR: 2.7 (1.03–7.613)]. This finding was parallel to the findings from Turkey and World Health Organization reports that showed the COVID-19 pandemic is more prevalent and more severe among people of advanced age than younger ones, which increased the perception of the advanced age as a risk group for COVID-19.³² This could be thought of, as with increasing age, perceptions of risk and vulnerability to COVID-19 infection will be increased.³⁰

Professionals who married were twice more likely to take COVID-19 vaccines compared to those who did not. It can be thought as people who were married and lived with their family would be more likely to have the behavior protecting their families from the infection.²²

Health-care workers who earned a higher monthly salary of 6194–9056 were three times more likely to take a COVID-19 vaccine [AOR: 2.623 (1.398 −4.923)] than those who earned less. This is in line with a study conducted on the general population that revealed higher acceptance of the COVID-19 vaccine among those who earned a higher income.^25,30

In this study, having family members tested positive and contact with infected patients was found to be non-significant. This finding contradicts a similar study on willingness to accept the COVID-19 vaccine and affecting factors among health-care professionals from Turkey and Egypt.^32,34 This is due to the perceived decrease in risk of transmission, complications, and death from Covid-19 disease reports from the media and less attention given to the disease as of its beginning.^32,34

Health professionals who did not trust the science to develop effective covid-19 vaccines were 70% less likely to take COVI D-19 vaccines [AOR = 0.293(0.110–0.782)] compared to their counterparts. This is supported by another study which revealed higher odds of vaccine hesitancy among participants who did not trust science to produce safe and effective.³⁵ This might be related to conspiracy theories and religious impressions towards the virus and the vaccines.

The probability of COVID-19 vaccine uptake was three times more likely among professionals who trusted the Ethiopian ministry of health to ensure the safety of the COVID-19 vaccine [AOR = 3.312 (1.802–6.085)] than those who did not trust the ministry of health. This finding is congruent with a study conducted in Greece that revealed health-care providers who trusted Greek Public Health Authorities were twice more likely to receive vaccines.¹⁸ This might be thought of as infodemic from other sources, which consequently influences the formal information reach out properly to the health-care providers.

Health professionals who were concerned about the risk of COVID-19 infection were nearly seven times more likely to take the COVID-19 vaccine [AOR = 7.455 (4.041–13.754)] compared to those who did not. This finding is in parallel with findings from a study conducted in the US.²² Despite its significance in bivariate logistic regression, variables like profession type, unit of work, and attitude towards vaccine were non-significant in multivariate logistic regression. This is contradictory to findings from other studies conducted among health-care providers^34,36.

Strength of the Study

In this study, the response rate of the study participants in the area was good enough. In an attempt to keep the validity and reliability; data was collected by a pretested questionnaire to ensure reliability. The Data collector was trained on questionnaire, method of data collection and data was collected by open data kit (ODK) to manage data quality.

Limitation of Study

The study was conducted in four sub-cities in 21 health centers and sampling was limited to primary government health centers and did not include private clinics and hospitals. Moreover, this study was based on a quantitative questionnaire. This research can be improved by adding qualitative questions. Recall bias could happen on the number of whether the HCPs had previous contact. Difficult to establish any causal relationship between COVID-19 vaccine uptake and associated factors due to cross-sectional study of the study. Selection bias might be introduced due to non-stratification of the health professionals.

Conclusions

Overall, COVID-19 vaccine uptake among health-care providers was found to be relatively high. However, it is not sufficient to achieve herd immunity to eradicate COVID-19 infection, which was reported to be at least 82.5% from studies on the population in America. Advanced age, being married, earning a higher monthly salary, having trust in science to develop vaccines, the FMoH to ensure the safety of the vaccines, and higher perceived risk of COVID-19 infections were associated with an increased rate of COVID-19 vaccine uptake. Systemic measures for educating the HCPs, and disseminating information on the efficacy and safety of the COVID-19 vaccine should be prioritized alongside strengthening the vaccination supply.

Recommendation

Based on the findings of this study, the following recommendations have been forwarded.

Federal Ministry of Health

• Work with influential and religious people to address health system mistrust.
• Building trust and confidence with health-care providers through different duties.
• Work with media owners and social media agents to address misinformation.
• Should put in place reasonable mandates to HCPs to increase vaccination rate.
• Clearly and continually communicate pre and post–marketing vaccine surveillance through media to address concerns toward vaccine safety and efficacy.

AARHB and Public Health Associations Should

• Should decentralize vaccination sites to increase vaccination coverage.
• Should develop special health plan to address disadvantaged groups such as women and low-income HCPs.

Health Centers

• Should encourage their respective health professionals to take vaccine.
• Should provide adequate information through formal channels.
• Work with peer group to increase awareness and risk perception of covid19.
• Encourage COVID-19 testing to increase acceptance rate.

Scholars and Expertise of Infectious Disease

• Large scale studies including both private health facilities and public health facilities should be conducted.
• This study suggests further qualitative studies to explore the actual reason behind health-care providers.