1. Introduction
The COVID-19 burden has increased around the world in disease, death, and economic crises.1 So that, COVID-19 pandemic was considered as a global health and a public health emergency. Since the beginning of the pandemic, the use of barrier measures in addition to hand washing and disinfection was the only solution to limit the transmission of this highly contagious virus. However, the long-awaited solution from the start of this scourge was the production of a new effective vaccine against this disease. Moreover, mass vaccination can lead to herd immunity without the requirement of a significant population being infected.2 Despite immense efforts made to develop a safe and effective vaccine, emergence of vaccine hesitancy during implementation was worrisome. As health-care professionals (HCP) were the first to face this emerging virus from the start of the pandemic, they were considered a priority for any vaccine that might be formed.3 Given that several studies reported controversial results about efficacy and safety of COVID-19 vaccine in the real world, attitudes towards COVID-19 vaccination among the general population was uncertain.4
In fact, studies demonstrated favorable attitudes from HCP; however, many also showed significant concerns primarily due to inadequate knowledge, a lack of trust and to the presence of anti-vaccine media.5 HCP intention to use and to recommend the vaccine to their patients depends on their knowledge and attitudes about vaccines. Actually, vaccine acceptability observed in the general population has been consistently linked to the level of vaccine acceptability among HCP, who would prescribe it to their patients.6 With this in mind, it become primordial to estimate HCP knowledge, attitudes, and practices regarding COVID-19 vaccine to improve its mass acceptability.
Patient hesitancy to get COVID-19 vaccine was related to multiple factors.7 It could be influenced by HCP knowledge and perception on the likelihood of the COVID-19 spread, vaccine safety, logistics, risks and on the efficacy of the vaccine.8
Understanding knowledge, attitudes, and practices of HCP regarding vaccination and their associated factors was of an utmost importance as the uptake of the vaccine is still below the anticipated and accepted levels, especially that the country has faced severe waves of COVID-19 pandemic. Moreover, it shall aid public health experts to create specific outcome‐based vaccine awareness strategies, and, consequently, will help to reduce the disease incidence.9
The Tunisian government started its vaccine rollout program on March 2021, primarily targeting HCP and the elderly. The program was continuously expanded to include adolescents as old as 12 years.10 , 11
At the current moment, vaccination is required in all governmental and most private institutions. In light of this, this study aimed to estimate knowledge, attitudes and practices’ levels regarding COVID-19 vaccination among HCP in Southern Tunisia and to identify their associated factors.
2. Methods
2.1. Study design and settings
This was a cross-sectional study using an anonymous self-administered questionnaire, including a randomized sample of HCP working at Hedi Chaker University Hospital (HCUH), Sfax, Southern Tunisia, from March, 1st to April 30th, 2021.
2.2. Inclusion criteria and sampling procedures
All HCP aged 18 years or older working at HCUH and who accepted to respond to the questionnaire were eligible for this study. Excluded cases were those who had retired or gave incomplete responses. In order to obtain a representative sample of the participants, HCP in each department were randomly selected proportionally to the number of each professional category in HCUH. Based on a 4% margin of error, a rate of 88% of good attitude about COVID-19 vaccination published in a previous similar study and a confidence level of 95%, the minimum sample size was at least 254 HCP.12
2.3. Data collection
Knowledge, attitudes, and practices were assessed using a 57-item questionnaire. The data collection tool included in the first part 13 items about HCP socio-demographics, working conditions and seniority, health status and previous infection with COVID-19. The second part consisted of 6 items to assess knowledge about COVID-19 vaccine. The third part comprised HCP attitudes, including 33 items to consider their beliefs as well as their future recommendations towards COVID-19 vaccine. The last part, with 5 items, included HCP practices towards COVID-19 vaccination. Participation to the survey was completely voluntary and HCP identities were anonymous for maximum of privacy and confidentiality.
2.4. Scoring method
For knowledge, each correct answer was given 1 point and 0 point for incorrect answers. The higher the points, the more knowledgeable the HCP is. For attitudes, response to each item was recorded on a 5-point-Likert scale from 1 to 5 (1 = strongly disagree, 2 = disagree, 3 = uncertain, 4 = agree, 5 = strongly agree). As for practices, the assessment of the participant's response was composed of 2 behaviors « yes » or « no ». Answers that reflected good practice were given 1 point, while zero was given for bad practice. For each section, a score was calculated by summing up the answers of each item. Then, these scores were adjusted out of 100 points. Subsequently, according to the median of each score, respondents were categorized according to their scores into good (median value of knowledge score≥52.32) or bad knowledge, having positive (median value of attitudes score≥86.18) or negative attitudes and good (median value of practices score≥80.00) or bad practices of HCP towards COVID-19 vaccination.
2.5. Statistical analysis
Data were analyzed using SPSS.26 version. Continuous variables were presented as mean ± standard deviation or median and interquartile range (IQR), according to the normality of the variable distribution. Categorical variables were presented as percentages. Univariate logistic regression was performed to compare two categorical variables in independent samples [Crude Odds Ratio (COR); 95% Confidence Interval (95% CI), p)]. Then factors statistically associated with good knowledge, attitudes and practices in the univariate analysis were entered into three multivariate models using logistic binary regression [adjusted Odds Ratio; (AOR) 95% CI, p] in order to identify the independent factors of good knowledge, positive attitudes and good practices towards COVID-19 vaccination. P values lower than 0.05 were considered statistically significant.
3. Results
3.1. Description of the study population
Overall, 300 subjects responded to the questionnaire out of 328 enrolled HCP, giving a response rate of 90%. There were 223 females (74.3%), with a sex-ratio (male/female) of 0.34. The mean age was 29.5 ± 8.26 years. There were 178 (59.33%) medical doctors. According to the work seniority, 243 participants (81%) had <10 years of work experience. Moreover, 164 (54.7%) HCP were working at medical units. History of chronic diseases were noted among 53 HCP (17.7%). We found that 115 subjects were married (38.34) and 259 cases (86.3%) were living in urban residencies. As for educational level, 254 HCP (84.7%) had a high postgraduate degree (Table 1 ).
Table 1.
Description of the study population.
| Variables | Total (N, %) |
|---|---|
| Socio-demographics | |
| Gender | |
| Females | 223 (74.3) |
| Males | 77 (25.6) |
| Education level | |
| Secondary school | 46 (16) |
| Post-graduated | 254 (84.7) |
| Marital status | |
| Married | 115 (38.3) |
| Unmarried | 185 (61.67) |
| Residency | |
| Rural | 41 (13.7) |
| Urban | 259 (86.3) |
| Occupation | |
| Paramedical | 122 (40.67) |
| Medical doctors | 178 (59.3) |
| Department | |
| Medical | 164 (54.7) |
| Surgical | 77 (25.7) |
| Intensive care units | 59 (19.7) |
| Chronic diseases | 53 (17.7) |
| Previous infection with COVID-19 | 75 (25) |
| Direct contact with COVID-19 positive patients | 150 (50) |
| Previous contact with positive covid-19 co-workers | 219 (73) |
*N: Number; %: percentage.
3.2. Knowledge, attitudes, and practices towards COVID-19 vaccination
The scores’ median values of COVID-19 vaccine knowledge, attitudes and practices among HCP were 52.3 (IQR = [47–61]), 86.1 (IQR = [75.1–91.4]) and 75.9 (IQR = [60–80]) out of 100, respectively. We noted that 196 HCP (65.3%) had good knowledge, 173 participants (57.7%) had positive attitudes and 217 subjects (72.3%) had good practices towards COVID-19 vaccination.
3.3. Factors associated with good knowledge, positive attitudes, and good practices
3.3.1. Univariate analysis
Univariate analysis showed that urbanity of residence was statistically associated with good knowledge and positive attitudes (COR = 2.5; p = 0.006) and (COR = 2.44; p = 0.009), respectively). Medical doctors had a statistically higher rate of good knowledge, positive attitudes and good practices (COR = 2.5; p < 0.001), (COR = 2.46; p < 0.001) and (COR = 1.91; p = 0.012), respectively). Direct contact with COVID-19 positive patients was statistically associated with good knowledge and good practices ((COR = 1.81; p = 0.015) and (COR = 2.03; p = 0.007), respectively). Good knowledge, positive attitudes and good practices were statistically associated with post-graduated educational level ((COR = 2.56; p < 0.001), COR = 2.53; p < 0.001) and COR = 1.95; p = 0.01), respectively).
Good knowledge was statistically associated with positive attitudes and good practices ((COR = 2.05; p = 0.003) and (COR = 2.75; p < 0.001), respectively). Positive attitudes were statistically associated with good practices (COR = 4.2; p < 0.001) (Table 2 ).
Table 2.
Factors associated with good knowledge, positive attitudes and good practices regarding COVID-19 vaccine among healthcare professionals: results of univariate analysis.
| Variables | Good knowledge |
Positive attitudes |
Good practices |
||||||
|---|---|---|---|---|---|---|---|---|---|
| N (%) | COR [95% CI] | p | N (%) | COR [95% CI] | p | N (%) | COR (95% CI) | p | |
| Gender | |||||||||
| Males | 55 (71.4%) | 1 | 0.19 | 46 (59.7%) | 1 | 0.67 | 59 (76.6%) | 1 | 0.33 |
| Females | 141 (63.2%) | 0.68 [0.39–1.21] | 127 (57%) | 0.89 [0.53–1.51] | 158 (70.9%) | 0.74 [0.41–1.35] | |||
| Residency | |||||||||
| Rural | 19 (46.3%) | 1 | 0.006 | 16 (39%) | 1 | 0.009 | 188 (72.6%) | 1 | 0.80 |
| Urban | 177 (68.3%) | 2.5 [1.28–5] | 157 (60.6%) | 2.38 [1.22–4.76] | 29 (70.7%) | 0.91 [0.44–1.88] | |||
| Marital status | |||||||||
| Married | 70 (60.9%) | 1 | 0.2 | 72 (62.6%) | 1 | 0.17 | 85 (73.9%) | 1 | 0.63 |
| Unmarried | 126 (68.1%) | 1.37 [0.84–2.23] | 101 (54.6%) | 0.72 [0.45–1.16] | 132 (71.4%) | 0.88 [0.52–1.48] | |||
| Chronic diseases | |||||||||
| No | 167 (67.6%) | 1 | 0.07 | 146 (59.1%) | 1 | 0.27 | 181 (73.3%) | 1 | 0.43 |
| Yes | 29 (54.7%) | 0.58 [0.32–1.06] | 27 (50.9%) | 0.72 [0.39–1.30] | 36 (67.9%) | 0.77 [0.41–1.46] | |||
| Professional category | |||||||||
| Paramedical staff | 64 (52.9%) | 1 | <0.001 | 54 (44.6%) | 1 | <0.001 | 78 (64.5%) | 1 | 0.012 |
| Medical doctors | 132 (73.7%) | 2.5 [1.53–4.07] | 119 (66.5%) | 2.46 [1.53–3.95] | 139 (77.7%) | 1.92 [1.15–3.19] | |||
| Educational level | |||||||||
| Secondary school | 63 (52.5%) | 1 | <0.001 | 53 (44.2%) | 1 | <0.001 | 77 (64.2%) | 1 | 0.01 |
| Post-graduated | 133 (73.9%) | 2.56 [1.57–4.17] | 120 (66.7%) | 2.53 [1.57–4.06] | 140 (77.8%) | 1.95 [1.17–3.26] | |||
| Department | |||||||||
| Medical | 112 (68.3%) | 1 | 0.42 | 101 (61.6%) | 1 | 0.32 | 118 (72%) | 1 | 0.49 |
| Intensive care units | 38 (64.4%) | 0.84 [0.44–1.57] | 0.58 | 31 (52.5%) | 0.69 [0.38–1.26] | 0.22 | 46 (78%) | 1.38 [0.68–2.78] | 0.37 |
| Surgical | 46 (59.7%) | 0.68 [0.39–1.21 | 0.19 | 41 (53.2%) | 0.71 [0.41–1.23] | 0.22 | 53 (68.8%) | 0.86 [0.47–1.55] | 0.62 |
| Working seniority | |||||||||
| <10 | 162 (66.7%) | 1 | 0.31 | 137 (56.4%) | 1 | 170 (70%) | 1 | 0.06 | |
| ≥10 | 34 (59.6%) | 0.74 [0.41–1.34] | 36 (63.2%) | 1.33 [0.73–2.4] | 0.351 | 47 (82.5%) | 2.02 [0.97–4.21] | ||
| Direct contact with COVID-19 positive patients | |||||||||
| No | 88 (58.7%) | 1 | 0.015 | 85 (56.7%) | 1 | 0.73 | 98 (65.3%) | 1 | 0.007 |
| Yes | 108 (72%) | 1.81 [1.12–2.93] | 88 (58.7%) | 1.08 [0.68–1.72] | 119 (79.3%) | 2.04 [1.21–3.42] | |||
| Previous COVID-19 infection | |||||||||
| No | 148 (65.8%) | 1 | 0.78 | 133 (59.1%) | 1 | 0.38 | 166 (73.8%) | 1 | |
| Yes | 48 (64%) | 0.92 [0.53–1.59] | 40 (53.3%) | 0.79 [0.47–1.34] | 51 (68%) | 0.75 [0.43–1.33] | 0.33 | ||
| knowledge | |||||||||
| Bad | – | – | – | 48 (46.2%) | 1 | 0.003 | 61 (58.7%) | 1 | <0.001 |
| Good | – | – | – | 125 (63.8%) | 2.05 [1.26–3.33] | 156 (79.6%) | 2.75 [1.63–4.63] | ||
| Attitudes | |||||||||
| Negative | 71 (55.9%) | 1 | 0.003 | – | – | – | 71 (55.9%) | 1 | <0.001 |
| Positive | 125 (72.3%) | 2.05 [1.27–3.33] | – | – | – | 146 (84.4%) | 4.26 [2.48–7.31] | ||
| Practices | |||||||||
| Bad | 40 (48.2%) | 1 | <0.001 | 27 (32.5%) | 1 | <0.001 | – | – | – |
| Good | 156 (71.9%) | 2.75 [1.63–4.64] | 146 (67.3%) | 4.2 [2.48–7.31] | – | – | – | ||
*COR: Crude Odds Ratio/CI: Confidence Interval/N: Number/%: Percentage.
3.3.2. Multivariate analysis
Multivariate analysis showed that good knowledge was independently associated with medical doctor occupational category ((Adjusted Odds Ratio (AOR) = 2.28; p = 0.001) and good practices (AOR = 2.5; p = 0.001).
Positive attitude was independently associated with good practices (AOR = 3.96; p < 0.001) and medical doctor occupational category (AOR = 2.21; p = 0.002).
Direct contact with COVID-19 positive patients (AOR = 1.93; p = 0.02), good knowledge (AOR = 2.15; p = 0.007) and positive attitudes (AOR = 3.97; p < 0.001) were independent factors of good practice (Table 3 ).
Table 3.
Factors associated with good knowledge, positive attitudes and good practices regarding COVID-19 vaccine among healthcare professionals: results of multivariate analysis.
| Variables | Good knowledge |
Positive attitudes |
Good practices |
|||
|---|---|---|---|---|---|---|
| AOR [95% CI] | p | AOR [95% CI] | p | AOR (95% CI) | p | |
| Professional category | ||||||
| Paramedical staff | 1 | 0.001 | 1 | 0.002 | – | – |
| Medical doctors | 2.28 [1.39–3.77] | 2.21 [1.35–3.63] | – | – | ||
| Direct contact with COVID-19 positive patients | ||||||
| No | – | – | – | 1 | 0.02 | |
| Yes | – | – | – | 1.93 [1.11–3.38] | ||
| Knowledge | ||||||
| Bad | – | – | – | – | 1 | 0.007 |
| Good | – | – | – | – | 2.15 [1.23–3.76] | |
| Attitudes | ||||||
| Negative | – | – | – | – | 1 | <0.001 |
| Positive | – | – | – | – | 3.97 [2.27–6.94] | |
| Practices | ||||||
| Bad | 1 | 0.001 | 1 | <0.001 | – | – |
| Good | 2.5 [1.46–4.26] | 3.96 [2.28–6.85] | – | – | ||
*AOR: Adjusted Odds Ratio/CI: Confidence Interval.
3.3.3. Validity of the models
The results of Hosmer-Lemshow chi-square testing for the 3 models of good knowledge, positive attitudes and good practices ((χ 2 = 3.63; p = 0.16), (χ 2 = 0.057; p = 0.9) and (χ 2 = 7.14; p = 0.3), respectively) were indicatives of good calibration. The AUROC of the predictive logistic regression models were ((0.7; p < 0.001), (0.71; p < 0.001); and (0.74; p < 0.001), respectively) indicating good predictive power in discriminating, with a sensitivity and specificity of ((0.60; 0.76), (0.60; 0.71) and (0.73; 0.68), respectively).
4. Discussion
Despite the urgent necessity of generalizing the vaccination against COVID-19 virus, the rates of vaccinated people were extremely variable across the globe.13 In fact, knowledge, attitudes and practices seemed to be the modulators of vaccination reliance among individuals. HCP are one of the key population clusters that should be vaccinated, given the enormous risk of transmission. Therefore, the assessment of knowledge, attitudes and practices towards COVID-19 vaccination and their determinants, among this professional category is about a considerable importance.
Our study showed that nearly the two-thirds of the study population had good knowledge, over than the half of HCP had positive attitudes and more than 70% of the participants had good practices towards COVID-19 vaccination. The rate of good knowledge in our study was similar to other findings from Uganda 69%, but lower than those of other cross-sectional studies conducted in Nepal 79%, Saudi Arabia and China 89%.14, 15, 16, 17 On the other hand, this result was higher than the good knowledge level reported in Dubai (57%).18 These discrepancies between good knowledge frequencies among HCP from different countries could be explained by the variance in the information disseminated by media and social networks about COVID-19 vaccination; given that they were considered as the main sources of information about this theme.12
An interesting finding in this study was that medical doctor occupational category was independently associated with good knowledge. This result was in accordance with previous similar data from China and Congo, with respective AOR of 3.07 and 1.59.6 , 13 This might be related to the particular interest of doctors for this new vaccine and the continual concern that they had about self and others protection as well as patients safeguard. Another possible explanation was that doctors would be the prescribers of the new vaccine to their patients and they will be asked to inform patients about it. Thus, they were required to give the maximum of knowledge about this vaccine.
It was not surprising to find that good practice was independently associated with good knowledge. This association between good knowledge and vaccine good practice has been demonstrated in previous published studies. An Emirate study mentioned that there was a major association between good knowledge and vaccine practice (AOR = 3.57).19 Additionally, other published studies indicated that insufficient knowledge and data about vaccine was the considerable reason of non-practice of COVID-19 vaccine.20, 21, 22 Evidently, having sufficiently enriched personal knowledge about the new vaccine, its benefits on human health and its role to stop the pandemic worldwide would consequently have a good impact on promoting vaccine acceptability and then vaccine practice.
Similar to other published data, this current study found that positive attitudes toward COVID-19 vaccination were independently associated with medical doctor occupational category.6 , 23 , 24 There may be some reasons for this phenomenon; such as misunderstanding of vaccines by paramedical and other HCP categories, lower risk perception than doctors and possible less fear of COVID-19 transmission.23 Additionally, it has been reported that doctors declared more confidence in vaccines compared to other HCP categories, which could also explain in part this association.25 The veritable reasons why paramedical staff were less willing to receive the vaccine should be explored in further researches. Our results showed that positive attitudes to get COVID-19 vaccine was independently associated with good practice. This finding was not in line with literature, which illustrated no association between attitudes and practices towards COVID-19 vaccination among HCP.26 , 27 To our sense, it could be considered as evidence, as trust in vaccine was the key to have good practice towards it. In general, positive attitude towards vaccination was always essential to have more vaccine confidence as this helps to reduce vaccine hesitancy and reluctance.
Direct contact with COVID-19 positive patients was an independent factor of good practice according to this study. This fact was supported by previous data and could mirror the variability in the perceived risk of COVID-19 infection among HCP.28 When taking care of COVID-19 infected patients, this contact could be a source of stress, anxiety, and fear among HCP. Consequently, the vaccine remained not only a principal solution to minimize the menace of COVID-19 transmission at work, but also an additional psychological reassurance to be more comfortable while taking care about their patients as protected.
To the best of our knowledge, this original study was the first one enlightening the levels and the determinants of knowledge, attitudes, and practices towards the COVID-19 vaccine among HCP. Because it was carried out on a representative randomized sample, this survey would be a useful tool to estimate afterwards the vaccine knowledge attitudes and practices in the general population. Nevertheless, there are some limitations. This survey was conducted at a time of a peak of COVID-19 pandemic in Tunisia and just before the initiation of vaccine administration to HCP, which could make the findings particularly suitable and relevant. Moreover, regardless of the considerable number of the participants and the sample representability, a single-city study form could bias the representability of our findings to other circumstances and other populations.
High rates of good knowledge, positive attitudes and good practices regarding anti-COVID-19 vaccination were observed among HCP in Southern Tunisia. The main determinants of these indicators were potentially related to professional factors. Therefore, the Tunisian government and policymakers in the health sectors should address the concerns of HCP to plan training sessions continuously to rise HCP awareness about this preventive measure effectiveness and benefits in order to promote the vaccine acceptability in the general population.
Funding
None.
CRediT authorship contribution statement
Mouna Baklouti: wrote the article and/or revised the article for important intellectual content., Substantial contribution to conception and design of the study, to data acquisition, or to data analysis and interpretation.. Houda Ben Ayed: read and approved the final version of the submitted manuscript., Substantial contribution to conception and design of the study, to data acquisition, or to data analysis and interpretation., wrote the article and/or revised the article for important intellectual content.. Nouha Ketata: read and approved the final version of the submitted manuscript., Substantial contribution to conception and design of the study, to data acquisition, or to data analysis and interpretation.. Hanen Maamri: Substantial contribution to conception and design of the study, to data acquisition, or to data analysis and interpretation., read and approved the final version of the submitted manuscript.. Raouf Karray: read and approved the final version of the submitted manuscript.. Jihene Jdidi: read and approved the final version of the submitted manuscript.. Yosra Mejdoub: read and approved the final version of the submitted manuscript.. Mondher Kassis: read and approved the final version of the submitted manuscript.. Sourour Yaich: read and approved the final version of the submitted manuscript.. Jamel Dammak: read and approved the final version of the submitted manuscript., All Authors revised the manuscript and gave their contribution to improve the paper., All authors read and approved the final manuscript.
Declaration of competing interest
None.
Acknowledgement
None.
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