COVID-19 and COVID-19 vaccination experiences and perceptions among health workers during the pandemic in Ebonyi state, Nigeria: An analytical cross-sectional study

Ugwu I Omale; Cordis O Ikegwuonu; Glory E Nkwo; Ugochi I A Nwali; Olaedo O Nnachi; Okechukwu O Ukpabi; Ifeyinwa M Okeke; Richard L Ewah; Osarhiemen Iyare; Chidinma I Amuzie; Onyinyechukwu U Oka; Victor U Uduma; Azuka S Adeke

doi:10.1371/journal.pone.0303172

. 2024 May 9;19(5):e0303172. doi: 10.1371/journal.pone.0303172

COVID-19 and COVID-19 vaccination experiences and perceptions among health workers during the pandemic in Ebonyi state, Nigeria: An analytical cross-sectional study

Ugwu I Omale ^1,^*, Cordis O Ikegwuonu ¹, Glory E Nkwo ², Ugochi I A Nwali ¹, Olaedo O Nnachi ¹, Okechukwu O Ukpabi ¹, Ifeyinwa M Okeke ¹, Richard L Ewah ^3,⁴, Osarhiemen Iyare ¹, Chidinma I Amuzie ², Onyinyechukwu U Oka ¹, Victor U Uduma ⁵, Azuka S Adeke ¹

Editor: Ayi Vandi Kwaghe⁶

¹Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital Abakaliki (AEFUTHA), Abakaliki, Ebonyi State, Nigeria

²Department of Community Medicine, Federal Medical Centre Umuahia, Umuahia, Abia State, Nigeria

³Department of Anaesthesia, Alex Ekwueme Federal University Teaching Hospital Abakaliki (AEFUTHA), Abakaliki, Ebonyi State, Nigeria

⁴Department of Surgery, Anaesthesia Unit, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria

⁵Department of Internal Medicine, Alex Ekwueme Federal University Teaching Hospital Abakaliki (AEFUTHA), Abakaliki, Ebonyi State, Nigeria

⁶Federal Ministry of Agriculture and Rural Development, NIGERIA

Competing Interests: The authors have declared that no competing interests exist.

^✉

* E-mail: omaleiu@gmail.com

Roles

Ugwu I Omale: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review & editing

Cordis O Ikegwuonu: Investigation, Methodology, Validation, Writing – review & editing

Glory E Nkwo: Methodology, Validation, Writing – review & editing

Ugochi I A Nwali: Investigation, Methodology, Validation, Writing – review & editing

Olaedo O Nnachi: Investigation, Methodology, Validation, Writing – review & editing

Okechukwu O Ukpabi: Investigation, Methodology, Validation, Writing – review & editing

Ifeyinwa M Okeke: Investigation, Methodology, Validation, Writing – review & editing

Richard L Ewah: Investigation, Methodology, Validation, Writing – review & editing

Osarhiemen Iyare: Investigation, Methodology, Validation, Writing – review & editing

Chidinma I Amuzie: Methodology, Validation, Writing – review & editing

Onyinyechukwu U Oka: Investigation, Methodology, Validation, Writing – review & editing

Victor U Uduma: Investigation, Methodology, Validation, Writing – review & editing

Azuka S Adeke: Investigation, Methodology, Validation, Writing – review & editing

Ayi Vandi Kwaghe: Editor

PMCID: PMC11081237 PMID: 38722899

Abstract

Background

COVID-19 continues to be a disease of global public health importance and requires long-term management and control. Health workers’ (previous) experiences and perceptions regarding the COVID-19 pandemic and COVID-19 vaccination/vaccination process will influence not only their subsequent use of control measures but also public experiences/perceptions. We explored the COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions, and their predictors, among the health workers in Ebonyi state, Nigeria.

Methods

We conducted an online-offline analytical cross-sectional survey between March 12 and May 9, 2022 among all categories of health workers (clinical/non-clinical, public/private) working/living in Ebonyi state who consented to participate and were selected by convenience/snowballing techniques. A structured electronic questionnaire was used to collect data: self-administered via WhatsApp and interviewer-administered via KoBoCollect for participants who did not have WhatsApp. Data was analysed using descriptive statistics and bivariate/multivariate generalized linear models.

Results

Of the 1276 health workers surveyed: 55.8% had strong COVID-19 experience and perception, 80.7% had good COVID-19 vaccination expectation and perception, and 87.7% had positive COVID-19 vaccination process experience and perception. The most important predictors of the extent and level of COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions were level of place of work (primary-secondary/tertiary), level of attitude towards COVID-19 (vaccination), and level of knowledge about COVID-19. Another important predictor was place of work (public/private).

Conclusions

The evidence indicate the factors that should guide subsequent policy actions in the strategies to enhance the COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions of health workers (and their use of control measures) in Ebonyi state, Nigeria, and other similar contexts. It also indicate factors to be considered by future policy actions regarding similar diseases.

Introduction

COVID-19 related morbidity and mortality is still occurring around the world, more than four years since the disease emerged by end of 2019 and became a pandemic in early 2020 [1,2]. Although it has been declared to no longer be a public health emergency of international concern [3], COVID-19 is still a fatal disease of global public health importance that requires long-term management and control [1]. Millions of new infections or re-infections and thousands of related deaths continue to occur around the world, especially from new variants of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which have the potential to cause resurgence [1,2]. Over 503000 COVID-19 cases and 10000 related deaths were confirmed globally between the 28-day period of 7 January and 4 June 2024 [2]. However, these statistics are underestimated as the rate of testing and reporting have reduced globally (and some countries no longer test and report) [1,2].

One of the factors sustaining the COVID-19 pandemic was the reduction in the use and observance of COVID-19 control measures (including non-acceptance of COVID-19 vaccination) by the public, including the health workers, and COVID-19 vaccination with the other preventive measures is one of the strategies for the long-term management of the pandemic [1]. Disease risk perception and confidence in the safety and effectiveness of vaccination and the vaccination process/system are factors that influence vaccination acceptance [4]. Health workers are at particular risk of contracting COVID-19 as a result of their regular and close contact with patients and this risk continues to be real because of their key roles in the management of the new COVID-19 infections or re-infections. Thus, the subsequent use of public health control measures, including COVID-19 vaccination, is very crucial for health workers. The acceptance/uptake of COVID-19 vaccination by health workers will be influenced by their (previous) experiences and perceptions regarding the COVID-19 pandemic, COVID-19 vaccination, and the vaccination process [5,6] and the use of other preventive measures will be influenced by their COVID-19 experiences and perceptions [7].

Strong belief that one or other persons have a disease based only on symptoms, irrespective of laboratory diagnoses, is not uncommon in Ebonyi state (and Nigeria/other African countries) where morbidity and mortality from many common diseases (with known causes based on scientific knowledge) are still attributed to superstitious causes (such as spiritual attacks). Such belief was perhaps more striking during the COVID-19 pandemic due to the unprecedented misinformation, disinformation, and conspiracy theories about COVID-19 and COVID-19 vaccination and could be an important determinant of healthy behaviours. Such belief was also observed among the health workers who are important opinion leaders on health matters and sources of health information for many people. The experiences and perceptions of health workers regarding the COVID-19 pandemic, COVID-19 vaccination, and the vaccination process are crucial, because of their influence on the experiences and perceptions of the general public, and an understanding of these experiences and perceptions, and the determinants, would be useful in the subsequent planning of tailored COVID-19 behaviour change communication strategies.

It was therefore imperative to explore the experiences and perceptions of health workers regarding the COVID-19 pandemic and COVID-19 vaccination and its processes in Ebonyi state. We carried out an extensive online and offline study to evaluate COVID-19 vaccination acceptance and the determinants among the health workers in Ebonyi state, Nigeria [8] and part of the study also explored the COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions, and their predictors, among the health workers during the COVID-19 pandemic in the state.

Methods

Study design and setting

The study was an analytical cross-sectional survey conducted between March 12 and May 9, 2022 in Ebonyi state. The study protocol is described elsewhere [8]. Ebonyi state is in the south-east geopolitical zone of Nigeria and had a projected population for 2021 of 3,313,229 based on the 2006 national census figure and a growth rate of 2.8%. Christianity is the most practiced religion. The state is divided into three senatorial zones, 13 Local Government Areas (LGAs) and 171 political wards. As of 2020, there were 784 orthodox health care facilities in the state: 566 public health facilities (two tertiary, 13 secondary and 551 primary) and 218 private health facilities (25 secondary and 193 primary) [9]. The two tertiary facilities were the Alex Ekwueme Federal University Teaching Hospital Abakaliki (AEFUTHA) and the National Obstetrics Fistula Centre (NOFIC). The 13 public secondary facilities were the 13 general hospitals in each of the 13 LGAs of the state while the 25 private secondary facilities were private and missionary hospitals.

Study participants and data collection

The study participants were the health workers in Ebonyi state, including all categories of health workers, both clinical and non-clinical staff in public and private health care sectors. They include primary health care workers (health attendants, community health extension workers, community health officers, nurses and midwives), orderlies, medical laboratory scientists and technologists, patent medicine vendors, pharmacists and pharmacy technicians, medical doctors, dental therapists, physiotherapists, dietician, general admin department staff, personnel department staff, account department staff, public relation officers, security personnel. Eligible health workers were those who were working or living in Ebonyi state and gave verbal consent. Eligible participants were selected by convenience and snowballing sampling techniques.

Data collection was via health workers survey using a structured self-administered and interviewer-administered questionnaire [8]. The sections of the questionnaire include sociodemographic characteristics; COVID-19 experiences and perceptions; basic knowledge of COVID-19; and attitude towards COVID-19 and COVID-19 vaccination. The electronic version of the questionnaire was programmed using the KoBoToolbox software and pre-tested among health workers who were later exempted from the survey. The design of the questionnaire was informed by published data and expert validation and pre-test were carried out by the study team [8]. More details of the data management and quality control are in the study protocol [8].

To increase acceptance rate, the investigators first made physical/phone contact with many health workers who were available and/or easily accessible and sought their consent. Thereafter, the web link for the self-administered electronic questionnaire was sent to the private WhatsApp pages of those who gave verbal consent and they were asked to, after completing the questionnaire, forward the web link to other eligible health workers they know within the study area. Interviewers also administered the questionnaire with KoBoCollect installed in android devices to health workers who did not have online contact and those living in rural areas with poor or no internet access. 1276 health workers successfully participated in the survey.

Data management and statistical analyses

The independent factors were sociodemographic characteristics, professional/work-related attributes, main and most trusted sources of information about COVID-19, level of knowledge of COVID-19, and level of attitude towards COVID-19 (vaccination). The basic knowledge of COVID-19 was assessed using 44 knowledge items: each correct response and incorrect responses were respectively scored “1” and “0”; the highest attainable score was 44 and lowest was zero for each participant; scores of ≥75% of 44 were categorised as good knowledge and <75% were poor knowledge. The attitude towards COVID-19 and COVID-19 vaccination was assessed using 16 attitude items: each item had five response options of strongly disagree, disagree, not sure, agree, and strongly agree and scored from “1” to “5” or “5” to “1” as appropriate; the highest attainable score was 80 and the lowest was 16 for each participant; scores of ≥75% of 80 were categorized as good attitude and <75% were poor attitude.

The main outcomes measures were the extent of COVID-19 experience and perception, level of COVID-19 vaccination expectation and perception, and level of COVID-19 vaccination process experience and perception. 5–8 questionnaire items were used to assess the experiences and perceptions of participants about COVID-19 and COVID-19 vaccination and the vaccination process. Each item had five response options and was scored from 0–4. The scores for the 5–8 items related to each outcome was summed for each participant and scores ≥50% of the total versus <50% were respectively considered to be: strong versus not strong COVID-19 experience and perception; good versus poor COVID-19 vaccination expectation and perception; and positive versus negative COVID-19 vaccination process experience and perception. More details are in the study protocol [8].

“Experience and perception” was explored as particular outcomes or variables due to the understanding that “experience” and “perception” are inextricably linked and influence each other. In the context of the COVID-19 pandemic, someone who have witnessed a case of COVID-19 in the neighbourhood might be more likely to perceive or believe that COVID-19 is real and that it is possible to get infected. Conversely, someone who perceive or believe that COVID-19 is real and that it is possible to get infected, will be more likely to experience (observe facts of) COVID-19 cases in the neighbourhood. This means that someone who perceive or believe that COVID-19 is not real and that it is not possible to get infected, will be more likely not to experience (not to observe facts of) COVID-19 cases in the neighbourhood because any case of COVID-19 in the neighbourhood (base on classical symptoms and or laboratory tests) can more easily be interpreted to be other diseases or “spiritual attack”.

The other outcomes were the dichotomized positive versus non-positive categories of COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions which were assessed with the five-category 5–8 questionnaire items. These outcomes include: fear of getting COVID-19 (very fearful/a little fearful versus not fearful at all/not fearful/not sure), fear of having severe side-effects from COVID-19 vaccination (not fearful at all/not fearful versus very fearful/a little fearful/not sure), etc.

Statistical analyses were done with Stata/SE version 15.1 (Stata Corp, College Station, TX, USA). Data was summarized using frequencies with proportions (expressed as percentages) and median with inter-quartile range as appropriate. Inferential statistics were done using generalized linear models (GLM) and at 2.5% significance level to correct for multiple comparisons. For dichotomous or categorical independent factors, prevalence difference in the outcomes with 97.5% CI and p-values were computed using binomial identity GLM models with robust standard errors. For continuous independent factors, coefficients in the outcomes with 97.5% CI and p-values were computed using the binomial identity GLM models.

All the independent factors were added to the GLM model in the adjusted analyses. For the binomial identity GLM models that failed to achieve convergence, gaussian identity GLM models were used instead [10].

Ethics statement

Ethical approval for this study was obtained from the Ebonyi State Health Research and Ethics Committee (EBSHREC/15/01/2022-02/01/2023) and Research and Ethics Committee of Alex Ekwueme Federal University Teaching Hospital Abakaliki (14/12/2021-17/02/2022). Verbal informed consent was obtained from the study participants during which the purpose the study, kind of participation, likely duration of participation, voluntary nature of participation, absence of potential harm, potential benefit, and confidential nature of the study were duly communicated to them.

Results

Sociodemographic and background characteristics

The sociodemographic and background (work-related) characteristics of the 1276 health workers who participated in the study are presented in Table 1. Of the 1276 participants, the median age (IQR) was 33 years (26–43) and the median years of working experience was 5 years (2–13). Majority of them were females (67.2%), were married (54.2%), had a tertiary education (56.9%), were clinical staff (87.0%), were working primarily in private health facilities (51.1%), and were working at primary health facilities (74.6%).

Table 1. Sociodemographic and background characteristics of the 1276 study participants.

	n	%
Gender
Male	419	32.8
Female	857	67.2
Age, median (IQR), years	33 (26–43)	–
Marital status
Married	691	54.2
Not married¹	585	45.8
Educational level
No formal education	10	0.8
Primary	36	2.8
Secondary	504	39.5
Tertiary	726	56.9
Work category or cadre
Non-clinical staff²	166	13.0
Clinical staff³	1110	87.0
Working experience, median (IQR), years	5 (2–13)	–
Primary place of work
Private health facility⁴	652	51.1
Public health facility⁵	624	48.9
Level of primary place of work
Primary health facility⁶	952	74.6
Secondary health facility⁷	39	3.1
Tertiary health facility⁸	285	22.3

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¹Separated or Divorced or Widowed or Never married (Single).

²Admin, Personnel, Account, Public relation officer, Security etc

³Patent medicine vendor, Primary health care worker (Health attendant, Community health extension worker, Community health officer, Nurse & midwife), Orderly, Medical laboratory scientist or technologist, Pharmacist or pharmacy technician, Medical doctor, and others (Dental therapist, physiotherapist, Dietician etc).

⁴Patent medicine vendor (PMV), Private pharmacy, Private laboratory, Private hospital or clinic, Missionary hospital.

⁵Primary health care (PHC) centre, General hospital, Federal tertiary health centre, and Federal university teaching hospital.

⁶PMV, Private pharmacy, Private laboratory, Private hospital or clinic, and PHC centre.

⁷Missionary hospital and General hospital.

⁸Federal tertiary health centre and Federal university teaching hospital.

COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions

The COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions of the 1276 health workers who participated in the study are presented in Table 2. Regarding COVID-19 experiences and perceptions: more of the participants (44.3%) were very fearful about getting COVID-19 followed by those who were a little fearful (19.1%); majority of them (52.7%) had the perception that it was highly possible for them to get COVID-19 followed by those who had the perception that it was not possible at all (19.0%); most of them (81.4%) were sure they had never gotten COVID-19 followed by those who were not sure about it (10.0%); and most of them (86.0%) did not know any person who had gotten COVID-19; etc (Table 2).

Table 2. COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions among the 1276 study participants.

	n	%		n	%
COVID-19 experiences & perceptions			COVID-19 vaccination expectations & perceptions
How fearful are you about getting COVID-19?			How important is it for you to receive COVID-19 vaccination?
Very fearful	565	44.3	Very important	670	52.5
A little fearful	244	19.1	Important	316	24.8
Not sure	51	4.0	Not sure	124	9.7
Not fearful	227	17.8	Not important	65	5.1
Not fearful at all	189	14.8	Not important at all	101	7.9
How possible is it for you to get COVID-19?			How fearful are you about severe side-effects from the vaccination?
Highly possible	673	52.7	Not fearful at all	431	33.8
A bit possible	150	11.8	Not fearful	172	13.5
Not sure	54	4.2	Not sure	106	8.3
Not possible	156	12.2	A little fearful	187	14.6
Not possible at all	243	19.0	Very fearful	380	29.8
How possible is it for you to get severe COVID-19?			What protection against COVID-19 will the vaccination give?
Highly possible	545	42.7	Full protection	742	58.2
A bit possible	154	12.1	Partial protection	188	14.7
Not sure	82	6.4	Not sure	214	16.8
Not possible	190	14.9	No protection	46	3.6
Not possible at all	305	23.9	No protection at all	86	6.7
Have you ever had COVID-19?			How do you trust the health workers giving the vaccination?
Yes, surely	38	3.0	Trust them very much	694	54.4
Yes, think so	21	1.6	Trust them	316	24.7
Not sure	128	10.0	Not sure	121	9.5
No, think so	51	4.0	Do not trust them	51	4.0
No, surely	1038	81.4	Do not trust them at all	94	7.4
Have you ever had severe COVID-19?			How do you trust the government providing the vaccination?
Yes, very serious	8	0.6	Trust them very much	622	48.7
Yes, a bit serious	12	0.9	Trust them	297	23.3
Not sure	13	1.0	Not sure	122	9.6
No, not serious	16	1.3	Do not trust them	103	8.1
No, not serious at all	10	0.8	Do not trust them at all	132	10.3
			COVID-19 vaccination process experiences & perceptions
Know any person who have had COVID-19?			Ever heard COVID-19 vaccination was available for receipt?
Yes, a very close person	45	3.5	Yes, many times	1225	96.0
Yes, a close person	49	3.8	Yes, once/few times	46	3.6
Yes, a distant person	41	3.2	Not sure	4	0.3
Yes, a very distant person	45	3.5	No, no time	1	0.1
No	1096	86.0	No, no time at all	0	0
Know any person who have had severe COVID-19?			Know a COVID-19 vaccination place?
Yes, a very close person	31	2.4	Yes, a very close place	725	56.8
Yes, a close person	30	2.4	Yes, a close place	202	15.8
Yes, a distant person	30	2.4	Yes, a far place	171	13.4
Yes, a very distant person	43	3.4	Yes, a very far place	50	4.0
No	46	3.6	No	128	10.0
Know any person who have died from COVID-19?			Frequency of COVID-19 vaccination at that place?
Yes, a very close person	17	1.3	Daily, down to twice a week	725	56.8
Yes, a close person	13	1.0	Once a week	22	1.7
Yes, a distant person	35	2.7	Once in two–four weeks	12	0.9
Yes, a very distant person	45	3.5	No fixed time	30	2.4
No	70	5.5	Do not know	359	28.1
			Queue at the vaccination place?
			No queue	631	49.4
			Short queue	220	17.2
			Do not know	270	21.2
			Long queue	25	2.0
			Very long queue	2	0.2
			How caring are the health workers at the vaccination place?
			Very caring	615	48.2
			Caring	269	21.1
			Not sure	260	20.4
			Not caring	1	0.1
			Not caring at all	3	0.2

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Regarding COVID-19 vaccination expectations and perceptions: majority of the participants (52.5%) had the perception that it was very important for them to receive COVID-19 vaccination followed by those who had the perception that it was important (24.8%); more of them (33.8%) were not fearful at all of severe side-effects from COVID-19 vaccination followed by those who were very fearful (29.8%); majority of them (58.2%) believed COVID-19 vaccination would give them full protection against COVID-19 followed by those who were not sure about it (16.8%); etc (Table 2). Regarding COVID-19 vaccination process experiences and perceptions: most of the participants (96.0%) said they had heard many times that COVID-19 vaccination was available for them to go and receive followed by those who said they had heard about it few times or once (3.6%); majority of them (56.8%) said they knew a very close COVID-19 vaccination place/site followed by those who said they knew a close place (15.8%); etc (Table 2).

Predictors of COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions

Prevalence estimates and crude and adjusted prevalence differences (for categorical independent factors) and coefficients (for continuous independent factors) and their respective 97.5% CI and p-values are presented in Tables 3–5. The crude and adjusted p-values of the overall effects of polychotomous independent factors are also presented.

Table 3. Association between sociodemographic and background factors and the extent of COVID-19 experience and perception among the 1276 study participants.

	Extent of COVID-19 experience & perception^*		Crude results		Adjusted results^**
	Strong n (%) 712 (55.8)	Not strong n (%) 564 (44.2)	cPD (97.5% CI) or cCoef (97.5% CI)	p value	aPD (97.5% CI) or aCoef (97.5% CI)	p value
Gender
Female	490 (57.2)	367 (42.8)	0	–	0	–
Male	222 (53.0)	197 (47.0)	-4.2% (-10.8–2.5)	0.1577	1.4% (-4.0–6.8)	0.5687
Age, years (coefficient)	–	–	0.2% (-0.1–0.5)	0.1372	0.4% (0.01–0.9)	0.0218
Marital status
Not married¹	319 (54.5)	266 (45.5)	0	–	0	–
Married	393 (56.9)	298 (43.1)	2.3% (-3.9–8.6)	0.4011	1.4% (-5.0–7.8)	0.6298
Educational level
None, primary, or secondary	335 (60.9)	215 (39.1)	0	–	0	–
Tertiary	377 (51.9)	349 (48.1)	-9.0% (-15.2–(-2.7))	0.0013	3.0% (-3.4–9.4)	0.2960
Work category
Clinical staff	620 (55.9)	490 (44.1)	0	–	0	–
Non-clinical staff	92 (55.4)	74 (44.6)	-0.4% (-9.7–8.8)	0.9164	10.7% (2.9–18.4)	0.0022
Working experience, years (coefficient)	–	–	0.2% (-0.2–0.6)	0.2485	-0.5% (-1–0.04)	0.0376
Primary place of work
Private health facility²	420 (64.4)	232 (35.6)	0	–
Public health facility³	292 (46.8)	332 (53.2)	-17.6% (-23.8–(-11.5))	<0.0001	0.6% (-5.9–7.2)	0.8366
Level of primary place of work
Tertiary health facility⁴	42 (14.7)	243 (85.3)	0	–	0	–
Primary health facility⁵ or secondary health facility⁶	670 (67.6)	321 (32.4)	52.9% (47.1–58.6)	<0.0001	53.8% (46.0–61.7)	<0.0001
Main source of information about COVID-19				0.0033^$		0.9023^$
Internet, social media (whatsapp, facebook), & SMS	70 (43.5)	91 (56.5)	0	–	0	–
Traditional media (television, radio, prints)	291 (58.0)	211 (42.0)	14.5% (4.4–24.5)	0.0012	0.7% (-8.1–9.6)	0.8523
Interpersonal⁷	351 (57.3)	262 (42.7)	13.8% (3.9–23.6)	0.0017	-0.8% (10.6–9.0)	0.8484
Most trusted source of information about COVID-19				0.0009^$		0.7794^$
Internet, social media (whatsapp, facebook), & SMS	54 (44.3)	68 (55.7)	0	–	0	–
Traditional media (television, radio, prints)	317 (61.2)	201 (38.8)	16.9% (5.8–28.1)	0.0007	2.8% (-6.5–12.2)	0.4973
Interpersonal⁷	341 (53.6)	295 (46.4)	9.4% (-1.7–20.4)	0.0570	2.8% (-7.4–12.9)	0.5429
Level of knowledge about COVID-19⁸
Poor	375 (50.9)	361 (49.1)	0	–	0	–
Good	337 (62.4)	203 (37.6)	11.5% (5.2–17.7)	<0.0001	13.0% (7.4–18.6)	<0.0001
Level of attitude towards COVID-19 (vaccination)⁹
Poor	21 (8.8)	218 (91.2)	0	–	0	–
Good	691 (66.6)	346 (33.4)	57.8% (52.6–63.1)	<0.0001	47.0% (40.7–53.2)	<0.0001

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cPD = Crude prevalence difference. aPD = Adjusted prevalence difference. cCoef = Crude coefficient. aCoef = Adjusted coefficient.

*COVID-19 experiences and perceptions score of ≥50% of the highest attainable score of 32 was strong experience and perception and <50% was not strong experience and perception.

**Adjusted for Basic knowledge of COVID-19; Attitude towards COVID-19 & COVID-19 vaccination; Source of information about COVID-19 (Main source and Most trusted source of information about COVID-19); Sociodemographic characteristics (Gender, Age, Marital status, Educational level); and Work related attributes (Work category, Years of working experience, Primary place of work (public and private), Level of primary place of work (primary, secondary, tertiary).

^$p value of overall effect.

¹Separated or Divorced or Widowed or Never married (Single).

²Patent medicine vendor (PMV), Private pharmacy, Private laboratory, Private hospital or clinic, Missionary hospital.

³Primary health care (PHC) centre, General hospital, Federal tertiary health centre, and Federal university teaching hospital.

⁴Federal tertiary health centre and Federal university teaching hospital.

⁵PMV, Private pharmacy, Private laboratory, Private hospital or clinic, and PHC centre.

⁶Missionary hospital and General hospital.

⁷Relatives/friends, health workers, place of work, place of worship etc.

⁸Knowledge score of <75% of the highest attainable score of 44 was poor knowledge and ≥75% was good knowledge.

⁹Attitude score of <75% of the highest attainable score of 80 was poor attitude and ≥75% was good attitude.

Table 5. Association between sociodemographic and background factors and the COVID-19 vaccination process experience and perception level among the 1276 study participants.

	COVID-19 vaccination process experience & perception level^*		Crude results		Adjusted results^**
	Positive n (%) 1119 (87.7)	Negative n (%) 157 (12.3)	cPD (97.5% CI) or cCoef (97.5% CI)	p value	aPD (97.5% CI) or aCoef (97.5% CI)	p value
Gender
Female	753 (87.9)	104 (12.1)	0	–	0	–
Male	366 (87.4)	53 (12.6)	-0.5% (-4.9–3.9)	0.7943	0.2% (-4.2–4.6)	0.9276
Age, years (coefficient)	–	–	0.2% (0.1–0.4)	0.0003	0.1% (-0.2–0.4)	0.4445
Marital status
Not married¹	488 (83.4)	97 (16.6)	0	–	0	–
Married	631 (91.3)	60 (8.7)	7.9% (3.7–12.1)	<0.0001	1.5% (-3.3–6.4)	0.4792
Educational level
None, primary, or secondary	456 (82.9)	94 (17.1)	0	–	0	–
Tertiary	663 (91.3)	63 (8.7)	8.4% (4.1–12.7)	<0.0001	5.7% (0.9–10.5)	0.0076
Work category
Clinical staff	973 (87.7)	137 (12.3)	0	–	0	–
Non-clinical staff	146 (87.9)	20 (12.1)	0.3% (-5.8–6.4)	0.9137	3.8% (-2.6–10.2)	0.1819
Working experience, years (coefficient)	–	–	0.5% (0.2–0.7)	<0.0001	0.06% (-0.2–0.4)	0.6535
Primary place of work
Private health facility²	548 (84.1)	104 (15.9)	0	–	0	–
Public health facility³	571 (91.5)	53 (8.5)	7.5% (3.4–11.5)	<0.0001	5.7% (1.6–9.9)	0.0020
Level of primary place of work
Tertiary health facility⁴	243 (85.3)	42 (14.7)	0	–	0	–
Primary health facility⁵ or secondary health facility⁶	876 (88.4)	115 (11.6)	3.1% (-2.1–8.4)	0.1796	9.3% (3.6–15.0)	0.0003
Main source of information about COVID-19				0.5577^$		0.0390^$
Internet, social media (whatsapp, facebook), & SMS	142 (88.2)	19 (11.8)	0	–	0	–
Traditional media (television, radio, prints)	434 (86.5)	68 (13.5)	-1.7% (-8.4–4.9)	0.5566	-6.8% (-14.7–1.1)	0.0533
Interpersonal⁷	543 (88.6)	70 (11.4)	0.4% (-6.0–6.8)	0.8934	-1.6% (-10.6–7.5)	0.6936
Most trusted source of information about COVID-19				0.7501^$		0.0670^$
Internet, social media (whatsapp, facebook), & SMS	105 (86.1)	17 (13.9)	0	–	0	–
Traditional media (television, radio, prints)	458 (88.4)	60 (11.6)	2.4% (-5.1–10.1)	0.4939	7.5% (-1.3–16.2)	0.0571
Interpersonal⁷	556 (87.4)	80 (12.6)	1.4% (-6.3–9.0)	0.6902	3.4% (-6.7–13.5)	0.4528
Level of knowledge about COVID-19⁸
Poor	600 (81.5)	136 (18.5)	0	–	0	–
Good	519 (96.1)	21 (3.9)	14.6% (10.9–18.3)	<0.0001	11.7% (7.7–15.6)	<0.0001
Level of attitude towards COVID-19 (vaccination)⁹
Poor	158 (66.1)	81 (33.9)	0	–	0	–
Good	961 (92.7)	76 (7.3)	26.6% (19.5–33.7)	<0.0001	21.3% (14.3–28.4)	<0.0001

Open in a new tab

cPD = Crude prevalence difference. aPD = Adjusted prevalence difference. cCoef = Crude coefficient. aCoef = Adjusted coefficient.

*COVID-19 vaccination process experiences and perceptions score of ≥50% of the highest attainable score of 20 was positive experience and perception and <50% was negative experience and perception.

^$p value of overall effect.

¹Separated or Divorced or Widowed or Never married (Single).

²Patent medicine vendor (PMV), Private pharmacy, Private laboratory, Private hospital or clinic, Missionary hospital.

³Primary health care (PHC) centre, General hospital, Federal tertiary health centre, and Federal university teaching hospital.

⁴Federal tertiary health centre and Federal university teaching hospital.

⁵PMV, Private pharmacy, Private laboratory, Private hospital or clinic, and PHC centre.

⁶Missionary hospital and General hospital.

⁷Relatives/friends, health workers, place of work, place of worship etc.

⁸Knowledge score of <75% of the highest attainable score of 44 was poor knowledge and ≥75% was good knowledge.

⁹Attitude score of <75% of the highest attainable score of 80 was poor attitude and ≥75% was good attitude.

The extent of COVID-19 experience and perception and the associations between it and sociodemographic and background factors are presented in Table 3. Among the 1276 study participants, 55.8% had strong COVID-19 experience and perception while 44.2% had not strong COVID-19 experience and perception. As shown by the adjusted results, the predictors of strong COVID-19 experience and perception were: being a health worker at a primary/secondary health facility (adjusted prevalence difference (aPD) 53.8%, 97.5% CI 46.0–61.7, p<0.0001); being a non-clinical health worker (aPD 10.7%, 2.9–18.4, p = 0.0022); good attitude towards COVID-19 (vaccination) (aPD 47.0%, 40.7–53.2, p<0.0001); good knowledge about COVID-19 (aPD 13.0%, 7.4–18.6, p<0.0001); and age as one year increase in age increases the probability of having strong COVID-19 experience and perception by 0.4% (adjusted coefficient (aCoef) 0.4%, 97.5% CI 0.01–0.9), p = 0.0218).

The level of COVID-19 vaccination expectation and perception and the associations between it and sociodemographic and background factors are presented in Table 4. Among the 1276 study participants, 80.7% had good COVID-19 vaccination expectation and perception while 19.3% had poor COVID-19 vaccination expectation and perception. The predictors of good COVID-19 vaccination expectation and perception were: being a health worker at a primary/secondary health facility (aPD 27.3%, 19.8–34.8, p<0.0001); being a health worker at a public health facility (aPD 6.0%, 1.7–10.3, p = 0.0017); good attitude towards COVID-19 (vaccination) (aPD 49.2%, 41.6–56.8, p<0.0001); and good knowledge about COVID-19 (aPD 7.4%, 3.1–11.7, p = 0.0001).

Table 4. Association between sociodemographic and background factors and the COVID-19 vaccination expectation and perception level among the 1276 study participants.

	COVID-19 vaccination expectation & perception level^*		Crude results		Adjusted results^**
	Good n (%) 1030 (80.7)	Poor n (%) 246 (19.3)	cPD (97.5% CI) or cCoef (97.5% CI)	p value	aPD (97.5% CI) or aCoef (97.5% CI)	p value
Gender
Female	698 (81.5)	159 (18.5)	0	–	0	–
Male	332 (79.2)	87 (20.8)	-2.2% (-7.6–3.1)	0.3542	2.8% (-1.7–7.3)	0.1688
Age, years (coefficient)	–	–	-0.04% (-0.3–0.2)	0.7368	-0.1% (-0.5–0.2)	0.3638
Marital status
Not married¹	462 (79.0)	123 (21.0)	0	–	0	–
Married	568 (82.2)	123 (17.8)	3.2% (-1.8–8.2)	0.1475	3.7% (-1.7–9.1)	0.1278
Educational level
None, primary, or secondary	456 (82.9)	94 (17.1)	0	–	0	–
Tertiary	574 (79.1)	152 (20.9)	-3.8% (-8.8–1.1)	0.0811	-1.1% (-5.8–3.6)	0.6080
Work category
Clinical staff	901 (81.2)	209 (18.8)	0	–	0	–
Non-clinical staff	129 (77.7)	37 (22.3)	-3.5% (-11.2–4.2)	0.3142	0.6% (-6.6–7.9)	0.8417
Working experience, years (coefficient)	–	–	0.1% (-0.2–0.4)	0.3862	-0.1% (-0.5–0.3)	0.5110
Primary place of work
Private health facility²	541 (83.0)	111 (17.0)	0	–	0	–
Public health facility³	489 (78.4)	135 (21.6)	-4.6% (-9.6–0.3)	0.0370	6.0% (1.7–10.3)	0.0017
Level of primary place of work
Tertiary health facility⁴	168 (59.0)	117 (41.0)	0	–	0	–
Primary health facility⁵ or secondary health facility⁶	862 (87.0)	129 (13.0)	28.0% (21.1–35.0)	<0.0001	27.3% (19.8–34.8)	<0.0001
Main source of information about COVID-19				0.0157^$		0.8582^$
Internet, social media (whatsapp, facebook), & SMS	115 (71.4)	46 (28.6)	0	–	0	–
Traditional media (television, radio, prints)	409 (81.5)	93 (18.5)	10.1% (1.2–18.9)	0.0112	0.5% (-8.2–9.3)	0.8920
Interpersonal⁷	506 (82.5)	107 (17.5)	11.1% (2.4–19.8)	0.0041	-1.2% (-11.1–8.8)	0.7925
Most trusted source of information about COVID-19				0.0083^$		0.1612^$
Internet, social media (whatsapp, facebook), & SMS	85 (69.7)	37 (30.3)	0	–	0	–
Traditional media (television, radio, prints)	432 (83.4)	86 (16.6)	13.7% (3.7–23.8)	0.0022	7.2% (-2.9–17.3)	0.1082
Interpersonal⁷	513 (80.7)	123 (19.3)	11.0% (1.0–21.0)	0.0135	9.8% (-1.7–21.2)	0.0564
Level of knowledge about COVID-19⁸
Poor	560 (76.1)	176 (23.9)	0	–	0	–
Good	470 (87.0)	70 (13.0)	10.9% (6.2–15.7)	<0.0001	7.4% (3.1–11.7)	0.0001
Level of attitude towards COVID-19 (vaccination)⁹
Poor	86 (36.0)	153 (64.0)	0	–	0	–
Good	944 (91.0)	93 (9.0)	55.0% (47.8–62.3)	<0.0001	49.2% (41.6–56.8)	<0.0001

Open in a new tab

cPD = Crude prevalence difference. aPD = Adjusted prevalence difference. cCoef = Crude coefficient. aCoef = Adjusted coefficient.

*COVID-19 vaccination expectations and perceptions score of ≥50% of the highest attainable score of 20 was good expectation and perception and <50% was poor expectation and perception.

^$p value of overall effect.

¹Separated or Divorced or Widowed or Never married (Single).

²Patent medicine vendor (PMV), Private pharmacy, Private laboratory, Private hospital or clinic, Missionary hospital.

³Primary health care (PHC) centre, General hospital, Federal tertiary health centre, and Federal university teaching hospital.

⁴Federal tertiary health centre and Federal university teaching hospital.

⁵PMV, Private pharmacy, Private laboratory, Private hospital or clinic, and PHC centre.

⁶Missionary hospital and General hospital.

⁷Relatives/friends, health workers, place of work, place of worship etc.

⁸Knowledge score of <75% of the highest attainable score of 44 was poor knowledge and ≥75% was good knowledge.

⁹Attitude score of <75% of the highest attainable score of 80 was poor attitude and ≥75% was good attitude.

The level of COVID-19 vaccination process experience and perception and the associations between it and sociodemographic and background factors are presented in Table 5. Among the 1276 study participants, 87.7% had positive COVID-19 vaccination process experience and perception while 12.3% had negative COVID-19 vaccination process experience and perception. The predictors of positive COVID-19 vaccination process experience and perception were: being a health worker at a primary/secondary health facility (aPD 9.3%, 3.6–15.0, p = 0.0003); being a health worker at a public health facility (aPD 5.7%, 1.6–9.9, p = 0.0020); having a tertiary education (aPD 5.7%, 0.9–10.5, p = 0.0076); good attitude towards COVID-19 (vaccination) (aPD 21.3%, 14.3–28.4, p<0.0001); and good knowledge about COVID-19 (aPD 11.7%, 7.7–15.6, p<0.0001).

Predictors of dichotomized (positive and non-positive) COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions

These results for the 1276 study participants are presented in S1 Appendix. Regarding COVID-19 experiences and perceptions, 63.4% were fearful of getting COVID-19 while 36.6% were not fearful/not sure and the predictors of being fearful of getting COVID-19 were being a health worker at a primary/secondary health facility, being a health worker at a public health facility, having a tertiary education, good attitude towards COVID-19 (vaccination), poor knowledge of COVID-19, and the most trusted source of information about COVID-19 (S1 Appendix p 2). 64.5% said it was possible for them to get COVID-19 while 35.5% said it was not possible or that they were not sure about it and the predictors of having the perception that it was possible to get COVID-19 were having a tertiary education, good attitude towards COVID-19 (vaccination), good knowledge about COVID-19, the most trusted source of information about COVID-19, and increase in age (S1 Appendix p 4).

Regarding COVID-19 vaccination expectations and perceptions, 77.3% said it was important for them to receive COVID-19 vaccination while 22.7% said it was not important or that they were not sure about it and the predictors of having the perception that it was important to receive COVID-19 vaccination were being a health worker at a primary/secondary health facility, being a health worker at a public health facility, being married, and good attitude towards COVID-19 (vaccination) (S1 Appendix p 6). 47.3% were not fearful of having severe side-effects from COVID-19 vaccination while 52.7% were fearful or not sure about it and the predictors of not being fearful of having severe side-effects from COVID-19 vaccination were being a health worker at a primary/secondary health facility, being a non-clinical health worker, having a tertiary education, good attitude towards COVID-19 (vaccination), good knowledge about COVID-19, the main source of information about COVID-19, and increase in age (S1 Appendix p 8). 72.9% said COVID-19 vaccination would give them protection against COVID-19 while 27.1% said it would give no protection or that they were not sure about it and the predictors of having the perception that COVID-19 vaccination would give protection against COVID-19 were being a health worker at a primary/secondary health facility, having a tertiary education, good attitude towards COVID-19 (vaccination), and the main source of information about COVID-19 (S1 Appendix p 10).

Regarding COVID-19 vaccination process experiences and perceptions, 72.7% knew a close COVID-19 vaccination place while 27.3% knew a far place or no place and the predictors of knowing a close COVID-19 vaccination place were being a health worker at a public health facility, good attitude towards COVID-19 (vaccination), and good knowledge about COVID-19 (S1 Appendix p 12).

Discussion

This study found that: 55.8% had strong COVID-19 experience and perception and the predictors were being a health worker at a primary/secondary health facility, being a non-clinical health worker, good attitude towards COVID-19 (vaccination), good knowledge about COVID-19, and increase in age; 80.7% had good COVID-19 vaccination expectation and perception and the predictors were being a health worker at a primary/secondary health facility, being a health worker at a public health facility, good attitude towards COVID-19 (vaccination), and good knowledge about COVID-19; and 87.7% had positive COVID-19 vaccination process experience and perception and the predictors were being a health worker at a primary/secondary health facility, being a health worker at a public health facility, having a tertiary education, good attitude towards COVID-19 (vaccination), and good knowledge about COVID-19.

In view of the uniqueness of the above outcome measures explored by the study (the extent and levels of COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions), we did not identify relevant studies with similar outcomes for appropriate comparison of findings (descriptive estimates and predictors). However, the moderate level of prevalence (55.8%) of strong COVID-19 experience and perception among the health workers perhaps reflected the fact that the pandemic was relatively less severe in Ebonyi state as fewer COVID-19 cases and related deaths were confirmed compared to many other settings.

The higher prevalence (80.7%) of good COVID-19 vaccination expectation and perception among the health workers despite the misinformation/disinformation and conspiracy theories about COVID-19 and COVID-19 vaccination in the media perhaps indicate that the misinformation/disinformation had limited negative effects on their perception of COVID-19 vaccination. This study was conducted in the context of increased availability and access to actual vaccination. As a result, the real experiences and close perceptions of vaccination attributes (importance, safety/side-effects, and effectiveness) among those who were, or knew others who were, already vaccinated, could have positively affected the health workers’ perceptions of the vaccination despite the misinformation/disinformation. However, more studies, particularly qualitative studies, are required to provide more insights in this regard. Moreover, public confidence in the trustworthiness of the social media as a source of COVID-19 information was reported to decline over time during the pandemic [11]. The social media was the primary source of most COVID-19 misinformation/disinformation. Hence, it is plausible to say that the negative effects of COVID-19 and COVID-19 vaccination misinformation/disinformation on health workers’ perception of COVID-19 and COVID-19 vaccination decreased over time during the pandemic partly because of decline in their trust in the social media regarding COVID-19. Also, the trust for other health workers who were giving the COVID-19 vaccination and for the government who provided the vaccination were among the five questionnaire items used to measure COVID-19 vaccination expectation and perception. As health workers, the participants would not surprisingly have relatively more trust for the vaccination system (compared to the general public for example) and this would have also enhanced the estimate for the level of COVID-19 vaccination expectation and perception.

Compared to the 80.7% who had good COVID-19 vaccination expectation and perception in our study, only 53.5% of health workers had positive perception of COVID-19 vaccines in another study in Nigeria [12] and 60.5% had good perception of COVID-19 vaccine in a study in Ethiopia [13]. These lower values could have resulted from the different nature, timing, population, and context of the studies compared to our study. The other Nigerian study was institutional based among only health workers in four tertiary hospitals, only online, and conducted much earlier during the initial waves of the pandemic (in late 2020) when there were much confusion and fear and no actual vaccines in Nigeria. Similarly, the Ethiopian study was institutional based, among only health workers in a city (zonal capital), and conducted much earlier (in May 2021) and only about two months after implementation of COVID-19 vaccination in the country. The aforementioned imply that the sociodemographic and professional attributes, and socioeconomic status of the participants in both studies would perhaps be quite different from those in our study. Also, unlike in our study, the participants in the other Nigerian study had no real experiences regarding actual COVID-19 vaccination (in terms of side-effects and effectiveness) while those in the Ethiopian study more likely had very limited real experiences regarding actual COVID-19 vaccination. Moreover, the outcome measure in our study (level of COVID-19 vaccination expectation and perception) with its measurement was quite different from that of the other studies.

The higher prevalence of 87.7% of positive COVID-19 vaccination process experience and perception among the health workers was an encouraging finding and indicate good ease of access and the appeal of the COVID-19 vaccination system to the health workers who are opinion leaders on health matters and are expected to contribute to making the vaccination process more accessible and appealing to the general public. More specifically, 72.7% of the health workers knew a close COVID-19 vaccination place, partly indicating good ease of access. However, in a study in Yemen [14], only 45.4% agreed that they had access to COVID-19 vaccination. This contrasting lower value could be due to the limited availability of COVID-19 vaccination in Yemen perhaps due to conflict-related constraints [14]. Although we identified no relevant studies to compare with, the above predictors identified by our study indicate factors that should be considered by policy makers and implementers in the strategies to enhance COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions among health workers in Ebonyi state, Nigeria and other similar contexts.

In our study, 63.4% were fearful of getting COVID-19, 64.5% said it was possible for them to get COVID-19, 77.3% said it was important for them to receive COVID-19 vaccination, 47.3% were not fearful of having severe side-effects from COVID-19 vaccination, and 72.9% said COVID-19 vaccination would give them protection against COVID-19. Respectively higher proportions were reported by a study in Nigeria [12] in which 91.4% perceived they were at risk of getting COVID-19 and about 80.0% agreed that the vaccine was protective. The contrasting finding could have resulted from the different nature, timing, population, and context of the study as already stated above.

Higher proportions were also reported by foreign studies: about 87.8% were afraid of getting COVID-19 in a study in Ethiopia [15], about 85.0% were afraid of getting COVID-19 at work in China [16], 94.1% thought it was possible for them to get COVID-19 in Saudi [17], 75.7% felt at risk of contracting COVID-19 at work in Saudi [18], and about 87.0% perceived they were at risk of getting COVID-19 in the next one year in the US [19]. Similarly, a higher proportion of 74.5% perceived they were at risk of getting COVID-19 but a slightly lower proportion of 69.9% believed in the effectiveness of the vaccination in another study in Ethiopia [13]. Also, a higher proportion of 89.8% had confidence in the effectiveness of COVID-19 vaccine in Malawi, however, a lower proportion of 41.0% thought it was possible for them to get COVID-19 in the next 12 months (but the study involved only exclusive group of health workers who had been offered the vaccination in their health facilities) [20]. Contrasting lower proportions were reported by a study in Yemen where 69.8% agreed that it was important for them to get vaccinated and 30.9% were not concerned (69.1% were concerned) about the side-effects of the vaccination [14].

The above contrasting findings (by the other previous studies) could perhaps be explained by the different nature, timing, population, and context of these studies as most were only online and involved limited categories of health workers and conducted much earlier, during the initial waves of the pandemic when there was much uncertainty, confusion, fear, and anxiety and when there were limited or no actual COVID-19 vaccines/vaccination. These contexts could have resulted in divergent sociodemographic and professional attributes, socioeconomic status, and real experiences of the study participants regarding COVID-19 and COVID-19 vaccination and differences in perceptions. Most of the studies were conducted when there were no actual COVID-19 vaccination and, as a result, the participants had no real experiences of the importance, safety/side-effects, and effectiveness of COVID-19 vaccination.

Although our study identified some predictors of the above dichotomized positive-negative COVID-19 and COVID-19 vaccination experiences and perceptions, we did not identify any relevant studies for appropriate comparisons as the above relevant and comparable studies did not assess predictors of COVID-19 and COVID-19 vaccination perceptions.

This study had some strengths. This study was not only online but also offline and among the entire populations and categories of health workers, in both rural and urban/semi-urban areas, in Ebonyi state. Hence, the study findings are more generalisable to the general population of health workers in the state and perhaps other poor resource settings with limited internet access. Other strengths were that the outcome measures and the potential covariates were pre-specified in the study protocol which was prospectively registered and prospectively submitted to a peer-review journal before the study was implemented.

One limitation in this study was reporting bias which is associated with questionnaire-based studies. The outcomes were measured by asking participants to report their COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions. Hence, they were prone to recall bias because some of these experiences and perceptions were past events. But the bias was minimal because such events were largely recurrent. Also, COVID-19/COVID-19 vaccination was a controversial topic due to the misinformation/disinformation and conspiracy theories, therefore, there was the tendency for some respondents to exaggerate desirable perceptions and underestimate undesirable perceptions. However, such bias was minimal because the questionnaire was anonymous and the respondents were assured of a high degree of confidentiality. In addition, there was increased possibility of selection bias from the convenience and snowballing sampling and this could limit the generalisability of the study findings to the target population.

Conclusions

There was moderate level of prevalence of strong COVID-19 experience and perception, high prevalence of good COVID-19 vaccination expectation and perception, and high prevalence of positive COVID-19 vaccination process experience and perception among the health workers during the COVID-19 pandemic in Ebonyi state, Nigeria. The most important predictors of the extent and level of COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions were level of primary place of work (primary/secondary versus tertiary facility), level of attitude towards COVID-19 (vaccination), and level of knowledge about COVID-19. Another important predictor was primary place of work (public/private facility). Subsequent COVID-19 and COVID-19 vaccination policy actions in Ebonyi state and Nigeria, and other similar contexts, should be guided by the evidence shown by this study in the strategies to improve health workers’ experiences and perceptions of COVID-19 and COVID-19 vaccination and the vaccination process in order to enhance subsequent acceptance/uptake of COVID-19 vaccination and use of other preventive measures. This study’s evidence will also guide policy actions/strategies regarding similar diseases in the future.

Subsequent studies on experiences and perceptions of COVID-19 and COVID-19 vaccination, or other infectious diseases/pandemic and their vaccinations, should not only describe prevalence among health workers but should also assess the predictors. Further studies, preferably qualitative studies, are needed on the factors that influence COVID-19 and COVID-19 vaccination (process) experiences and perceptions and particularly on the (positive) effects of health workers’ real experiences and close perceptions of COVID-19 vaccination attributes (importance, safety/side-effects, effectiveness) on COVID-19 vaccination expectations and perceptions in the middle of (the negative effects of) misinformation/disinformation and conspiracy theories.

Supporting information

S1 Appendix

(DOCX)

pone.0303172.s001.docx^{(80.3KB, docx)}

S1 Dataset

(XLSX)

pone.0303172.s002.xlsx^{(1.4MB, xlsx)}

Data Availability

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

Funding Statement

The authors received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0303172.r001

Decision Letter 0

Ayi Vandi Kwaghe

25 Sep 2023

PONE-D-23-24420COVID-19 and COVID-19 vaccination (process) experiences and perceptions and their predictors among health workers during the COVID-19 pandemic in Ebonyi state, Nigeria: an analytical cross-sectional studyPLOS ONE

Dear Dr. Omale,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Abstract

Please summarize the background, it is too robust for an abstract.

From my finding, the KoBoCollect, was accessed using a link through participants WhatsApp and those that didn’t have WhatsApp filled electronic questionnaire. Please, state clearly as such.

Conclusion line 54-58 please, rephrase.

Introduction

Do you mean the reduction in the use and observance of COVID-19 control measures and decrease in the COVID-19 vaccination acceptance by the public?

Line 76-76, please rephrase.

Line 89-92. Please rephrase.

The aim/objective of the study should be the last sentence in the introduction. Please, clearly state it in a sentence.

Delete line 108- “and the report of the findings are presented in this paper”

Methods

Study design and participants

Line 112- “all categories of health workers” please, state the categories of health workers interviewed clearly.

Clinical and nonclinical staff in the private health sector should be another sentence.

Line 114-“Eligible health workers”, inclusion criteria? Clearly state your inclusion and exclusion criteria for the study.

Line 114-115 “Eligible health workers were those who work or live in Ebonyi state and gave verbal consent and they were selected by convenience and snowballing techniques”

Selection process; ”sampling technique” applied for the study should be separated from eligibility criteria.

Line 114-115 “The study protocol is described elsewhere.7” state the link or cite the protocol that was used.

Line 115-123 should be under the topic data collection

Line 124 Independent factors and outcome measures; this should be under the title questionnaire as details that follow described the various sections of the questionnaire while the rest of the explanation should be part of the data analysis as it clearly described how the data from the responses were graded after analysis.

I noticed that there are a lot of repetitions with regard to the questionnaire

Clearly define your methodology:

• Study site/ study area: some details on the study site and health facilities in Ebonyi State.

• Study design

• Inclusion and exclusion criteria

• Sampling techniques

• Questionnaire design

• Ethical clearance and consent for participation

• Data management

o Data collection

o Data analysis

Results

Line 276, 282- please, do not start a sentence with a figure

Discussion

Line 295-297 seems like the aim of the study, please delete to avoid repetition.

Line 311-314, please refer the outcome of the study to Ebonyi State rather than generalizing it to Nigeria since the study was conducted in Ebonyi state and the method of sampling was not randomized.

Line 315-319 could it be generally classified as infodemic with regard to COVI-19 and COVID-19 vaccination?

Limitations of the study should be the last paragraph of the discussion.

Discuss the strength of the study before the limitations of the study.

Line 418-420 “Hence, the study findings are more generalizable to the general population of health workers in the state, other states in Nigeria, and other poor resource settings with limited internet access.”

The above statement mentioned that this study could be generalized to other states in Nigeria. Going by the sampling method that was used in the study could we generalize it to Nigeria? It will be more appropriate to limit our findings to Ebonyi State.

Conclusion

Line 438-446, this should be stated as part of the limitation of the study and also the appeal for further studies to cover the qualitative aspect of the current study. Rephrase and make it more concise to fit into part of the limitation of the study.

==============================

Please submit your revised manuscript by Nov 09 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Ayi Vandi Kwaghe, D.V.M., M.V.Sc., P.G.D.E. Ph.D., MPH

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: No

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: check your reference

Discussion:

- Please, discuss your results in details.

- Mention the limitations in study

Conclusion

Please rewrite conclusion again to be more informative.

Overall:

- I would advise that the manuscript is checked for grammatical and spelling errors

Reviewer #2: I can see that a lot of work has gone into this paper, the topic is relevant and pertinent. Unfortunately my sense is that at the moment it is not sufficiently rigorously enough designed, i.e. in terms of the meanings of the responses to illustrate new knowledge. The authors may wish to use some of the clearer questions to reanalyse the data to enhance rigour.

Title

Descriptive, appropriate, if a little long, could a few ands be omitted ?

Abstract

It’s detailed, but could benefit from a little clarification and a few more commas in places, or shorter sentences, as per sections highlighted in yellow.

‘Background: The COVID-19 pandemic continues to be a global emergency with

millions of new infections/re-infections and thousands of related deaths occurring

weekly globally and requires long-term management/control. One of the factors

sustaining the pandemic is the reduction in the use/non-use of control measures.

Health workers continue to be at high risk of contracting COVID-19 because of their

key roles in the management/control of the new COVID-19 infections/re-infections’

State needs capital letter, needs breaking up into shorter sentences.

‘Methods: We conducted an analytical online-offline cross-sectional survey between

March 12 and May 9, 2022 among all categories of health workers (clinical/non-clinical,

public/private) working/living in Ebonyi state who consented to participate and were

selected by convenience/snowballing techniques. A structured self-administered and

interviewer-administered electronic questionnaire, respectively via WhatsApp and

KoBoCollect, was used to collect data which was analysed using descriptive statistics

and bivariate/multivariate generalized linear models’

‘strong COVID-19 experience and perception, 80.7% had good COVID-19 vaccination expectation and

perception, and 87.7% had positive COVID-19 vaccination process experience and

perception. The most important predictors of the extent/level of COVID-19 and COVID19 vaccination (process) experiences and perceptions were level of place of work

(primary-secondary/tertiary), level of attitude towards COVID-19 (vaccination), and

level of knowledge about COVID-19. Another important predictor was place of work

(public/private).

Conclusions: There was moderate level of prevalence of strong COVID-19 experience

and perception, high prevalence of good COVID-19 vaccination expectation and

perception, and high prevalence of positive COVID-19 vaccination process experience

and perception among the health workers during the COVID-19 pandemic in Ebonyi

state, Nigeria’.

It might be advisable to reduce the contents of the abstract, as its not clear what some of these results mean in practice, e.g. ‘strong C-19 experience and perception‘

Intro

This is repetitious, and could be shortened e.g.

‘An understanding of health workers’ COVID-19 experiences and perceptions, and the determinants, would be useful in the subsequent planning of tailored COVID-19 behaviour change communication strategies’

Could the authors say what the determinants refers to, also what behaviour change they are referring to- is it increased vaccine take-up

Methods

Unfortunately the categories for many of the resulting questions are too vague to add new knowledge, what does ‘close’ ‘good’ ‘poor’ mean.

Results

As above

Discussion

Conclusion

At the moment this paper is not ready for publication. I'm not an expert on survey’s so perhaps I'm not the person to be reviewing here. The number of responses is very impressive, and the time and energy spent on recruitment and data analysis is impressive. However, my sense is that the questions and responses presented here are too vague to illustrate new knowledge.

If the authors can utilise and analyse some survey questions with really detailed, specific questions, and resubmit, with a clear aim, that could illustrate new knowledge, my sense is at the moment its not there.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

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PLoS One. 2024 May 9;19(5):e0303172. doi: 10.1371/journal.pone.0303172.r002

Author response to Decision Letter 0

6 Nov 2023

REVIEWERS’ COMMENTS AND RESEARCHERS’ RESPONSES

Thank you for your comments and for creating the time to review our manuscript.

Academic Editor

Abstract

1. Comment: Please summarize the background, it is too robust for an abstract.

Response: The background has been reduced

2. Comment: From my finding, the KoBoCollect, was accessed using a link through participants WhatsApp and those that didn’t have WhatsApp filled electronic questionnaire. Please, state clearly as such.

Response: It has been modified as appropriate (an electronic questionnaire administered via WhatsApp or KoboCollect for those that did not have WhatsApp)

3. Comment: Conclusion line 54-58 please, rephrase.

Response: It has been rephrased

Introduction

1. Comment: Do you mean the reduction in the use and observance of COVID-19 control measures and decrease in the COVID-19 vaccination acceptance by the public?

Line 76-76, please rephrase.

Line 89-92. Please rephrase.

Response: Yes. The statement regarding use of control measures refers to the general population which include the health workers. Both have been modified as appropriate.

2. Comment: The aim/objective of the study should be the last sentence in the introduction. Please, clearly state it in a sentence. Delete line 108- “and the report of the findings are presented in this paper”

Response: The phrase has been deleted and the statements regarding the aim has been modified as suggested.

Methods

Study design and participants

1. Comment: Line 112- “all categories of health workers” please, state the categories of health workers interviewed clearly. Clinical and nonclinical staff in the private health sector should be another sentence.

Response: We understand or believe the statement “… all categories of health workers, both clinical and non-clinical staff in public and private health care sectors, ...” is appropriately stated. The phrases “both clinical and non-clinical” and “public and private” already define the preceding phrase “all categories”. The clinical and non-clinical staff are respectively listed in the legend of table 1, including their categorization into public and private. Should the health workers still be listed in this section as they are in the legend of table 1?

2. Comment: Line 114-“Eligible health workers”, inclusion criteria? Clearly state your inclusion and exclusion criteria for the study.

Response: The eligibility criteria (which is also called inclusion and exclusion criteria) are already clearly stated. Please note that eligibility criteria can either be stated as “eligibility criteria” or separated into “inclusion and exclusion criteria”. We chose the former, and used it in the published protocol, as the latter is not always necessary and do not always add value (Reference: STROBE reporting guidelines). It will not be appropriate to separate it into the “inclusion and exclusion criteria” format at this stage.

3. Comment: Line 114-115 “Eligible health workers were those who work or live in Ebonyi state and gave verbal consent and they were selected by convenience and snowballing techniques”

Selection process; ”sampling technique” applied for the study should be separated from eligibility criteria.

Response: We used the unstructured format to reduce the number of subheadings and word count. They have been separated into different sentences in line with the suggestion.

4. Comment: Line 114-115 “The study protocol is described elsewhere.7” state the link or cite the protocol that was used.

Response: We seem not to understand this comment because the protocol is already cited (citation 7).

5. Comment: Line 115-123 should be under the topic data collection

Response: The statements in lines 112–119 (not 115–123) of the original manuscript were meant to describe the convenience and snowballing sampling technique. Some of them also fit into the “data collection” subsection. They have been merged under one subheading in line with other subsequent comments.

6. Comment: Line 124 Independent factors and outcome measures; this should be under the title questionnaire as details that follow described the various sections of the questionnaire while the rest of the explanation should be part of the data analysis as it clearly described how the data from the responses were graded after analysis.

I noticed that there are a lot of repetitions with regard to the questionnaire

Response: Please note that it will not be appropriate at all to use “questionnaire” as a subheading here because this section did not describe sections of the questionnaire. It rather described the relevant independent and outcome factors (regarding the aim of this study) which were created from items in the questionnaire and the explanations were descriptions of how these factors were created. For example, level of knowledge and level of attitude (as independent factors) and extent of COVID-19 experience and perception, level of COVID-19 vaccination expectation and perception, and level of COVID-19 vaccination process experience and perception (as outcome factors) were not questionnaire items. Also, the creation of these variables was done before analysis and ideally falls under “data management” and not “statistical analyses” and because of the extent of these variable creation, we believe it is better to put it under a separate subheading than “statistical analyses”. The methods section has been rearranged in response to other subsequent comments.

We do not understand what is meant by “a lot of repetitions with regard to the questionnaire” because there are no such repetitions. Please not that this section is not (and should not be seen as) description of sections of the questionnaire (which was under data collection). It is rather a description of the relevant independent and outcome factors which were created from items in the questionnaire. Also, extent/level of COVID-19 and COVID-19 vaccination (process) experiences and perceptions were a different set of outcome measures from the dichotomized positive versus non-positive categories of COVID-19 and COVID-19 vaccination (process) experiences and perceptions.

7. Comment: Clearly define your methodology:

• Study site/ study area: some details on the study site and health facilities in Ebonyi State.

• Study design

• Inclusion and exclusion criteria

• Sampling techniques

• Questionnaire design

• Ethical clearance and consent for participation

• Data management

o Data collection

o Data analysis

Response: The structure/subheadings in the method section has been modified as suggested. However, kindly note that the modification is also: in consideration of PLOS ONE Guidelines to authors to limit manuscript sections and sub-sections to 3 heading levels, in line with our foregoing responses, and in consideration of the fact that this study was nested in a larger study with a published protocol (and the need to maintain reasonable fidelity to the protocol). We do not understand what is actually meant by “questionnaire design”. The relevant sections of the questionnaire are already stated under data collection.

Results

Comment: Line 276, 282- please, do not start a sentence with a figure

Response: There were not new sentences but part of the statements under the “colon” in the opening sentence but the “semi-colons” to indicate these were omitted. These have been corrected.

Discussion

1. Comment: Line 295-297 seems like the aim of the study, please delete to avoid repetition.

Response: It has been deleted.

2. Comment: Line 311-314, please refer the outcome of the study to Ebonyi State rather than generalizing it to Nigeria since the study was conducted in Ebonyi state and the method of sampling was not randomized.

Response: It has been modified as suggested.

3. Comment: Line 315-319 could it be generally classified as infodemic with regard to COVI-19 and COVID-19 vaccination?

Response: Misinformation simply refers to false information. Disinformation is a specific type of misinformation created with the intention to deceive (that is, deliberate spread of false information). Both are preferred in this context. Infodemic simply means too much of information including false information and would not properly capture what we intend to emphasize.

4. Comment: Limitations of the study should be the last paragraph of the discussion.

Discuss the strength of the study before the limitations of the study.

Response: The order of the limitation and strength has been changed as suggested.

5. Comment: Line 418-420 “Hence, the study findings are more generalizable to the general population of health workers in the state, other states in Nigeria, and other poor resource settings with limited internet access.”

Response: The generalization as used in this context was in comparison to the only online studies as our study was both online and offline and thus, more representative of the general population of health workers (in urban and rural areas). However, it has been modified.

Conclusion

Comment: Line 438-446, this should be stated as part of the limitation of the study and also the appeal for further studies to cover the qualitative aspect of the current study. Rephrase and make it more concise to fit into part of the limitation of the study.

Response: We do not see this as limitation that should be placed under the “limitation” section. Such recommendation for further studies are common in relevant literature and are based on all the available evidence (from our study and other previous studies) as discussed under the “discussion” section.

Reviewer # 1

Comment: check your reference

Response: We do not understand what specific issue to check in the reference because no specific comment or suggestion was made. However, please note that we used software to manage the referencing and will crosscheck as appropriate.

Discussion

1. Comment: Please, discuss your results in details.

Response: We strongly believe the results have already been appropriately discussed in details.

2. Comment: Mention the limitations in study

Response: The limitations are already mentioned. Please see lines 413–423.

Conclusion

Comment: Please rewrite conclusion again to be more informative.

Response: We do not understand the comment. The conclusion is based on the study findings and the discussion of all available evidence.

Overall

Comment: I would advise that the manuscript is checked for grammatical and spelling errors

Response: The manuscript has been proof read again for typos and other errors

Reviewer # 2

Comment: I can see that a lot of work has gone into this paper, the topic is relevant and pertinent. Unfortunately my sense is that at the moment it is not sufficiently rigorously enough designed, i.e. in terms of the meanings of the responses to illustrate new knowledge. The authors may wish to use some of the clearer questions to reanalyse the data to enhance rigour.

Response: Please note that, as stated in the last part of the introduction section, this study was nested in a much larger study which was pre-registered before implementation and has a published study protocol which is also cited in this manuscript. As also stated in the “study strength” section, the outcomes and potential covariates were pre-specified in the study protocol. The statement “The authors may wish to use some of the clearer questions to reanalyse the data to enhance rigour” perhaps was due to lack of basic understanding of our study concepts and analyses.

Regarding the comment about new knowledge, please note the following:

(a) “New knowledge” is a spectrum and that in most cases, especially in applied disciplines/research, research evidence are not completely/absolutely new

(b) In many cases research evidence generation is incremental with subtle additions

(d) Research evidence in many (perhaps in most) cases are corroborative of existing evidence and need not to be completely/absolutely new to be of scientific or public health or health policy importance as the importance of any evidence is also context-specific.

Title

Comment: Descriptive, appropriate, if a little long, could a few ands be omitted?

Response: The study is analytical, not descriptive. Please note that there should be no inferential analysis (use of test statistics) in descriptive studies which should only be “descriptive” as the name indicate.

The title is not longer than necessary considering the nature/purpose of the study. Rather, in line with STROBE guidelines, the title appropriately captures the study design and research questions in addition to the participants and study setting.

Abstract

Comment: It’s detailed, but could benefit from a little clarification and a few more commas in places, or shorter sentences, as per sections highlighted in yellow.

‘Background: The COVID-19 pandemic continues to be a global emergency with

millions of new infections/re-infections and thousands of related deaths occurring

weekly globally and requires long-term management/control. One of the factors

sustaining the pandemic is the reduction in the use/non-use of control measures.

Health workers continue to be at high risk of contracting COVID-19 because of their

key roles in the management/control of the new COVID-19 infections/re-infections’

State needs capital letter, needs breaking up into shorter sentences.

Response: Shorter sentences cannot enhance clarification because the variable names are long. There is no highlighted section in the pasted quote. However, the abstract has been modified in line with the suggestions of the academic editor.

Please note that the primary word is “state” but “State” can also be used, when referring to a country (e.g Nigeria) or part of a country (e.g Ebonyi). Writing it as “Ebonyi state” is very okay. This can easily be confirmed using standard dictionaries e.g Oxford learners dictionaries. From experience, we very much understand that many scholars, particularly in Nigeria, do not understand the usage of the word as we have explained above.

Methods, Results, Conclusion

1. Comment: It might be advisable to reduce the contents of the abstract, as its not clear what some of these results mean in practice, e.g. ‘strong C-19 experience and perception‘

Response: There are no highlighted sections in all the pasted quotes. However, the abstract has been modified in line with the suggestions of the academic editor.

Also note that, as stated in the manuscript text under the methods section, the related questionnaire items were scored and the scores were summed and categorized (dichotomized) as strong versus not strong COVID-19 experience and perception using the 50th percentile as cutoff.

Introduction

Comment: This is repetitious, and could be shortened e.g. ‘An understanding of health workers’ COVID-19 experiences and perceptions, and the determinants, would be useful in the subsequent planning of tailored COVID-19 behaviour change communication strategies’ Could the authors say what the determinants refers to, also what behaviour change they are referring to- is it increased vaccine take-up

Response: Please note that due to the nature of the study and the concepts that were explored, the manuscript and manuscript sections are better understood as a whole. For example, to understand the statements in the above comment, you have to understand (and remember) all the preceding statements in the introduction.

For example, the preceding statement in lines 81–84 (of the revised manuscript) contains the behaviours being referred to subsequently in lines 97–98 and to continue to restate them will unnecessarily increase word count.

Also note that the determinants being referred to where the potential determinants the study set out to identify which could not be stated here under the introduction but rather presented as part of the findings in the result section.

Methods, Results

Comment: Unfortunately the categories for many of the resul

Attachment

Submitted filename: Response to Rviewers.docx

pone.0303172.s003.docx^{(43.1KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0303172.r003

Decision Letter 1

Ayi Vandi Kwaghe

1 Mar 2024

PONE-D-23-24420R1COVID-19 and COVID-19 vaccination (process) experiences and perceptions and their predictors among health workers during the COVID-19 pandemic in Ebonyi state, Nigeria: an analytical cross-sectional studyPLOS ONE

Dear Dr. Omale,

==============================

ACADEMIC EDITOR:

Study design and participants

“All categories of health workers” please, state the categories of health workers interviewed clearly.

It’s okay to have it in Table 1 of your results but you need to categorically state this in your methods for researchers that will be reading your article. Please clearly state these categories in your methods.

“Eligible health workers”, inclusion criteria? Clearly state your inclusion and exclusion criteria for the study.

Does this mean that all health workers in those facilities that gave their verbal consent were eligible without taken into consideration of other factors that may affect the parameters such as confounders? Were there people that met the inclusion criteria but could not be included in the study due to some reasons? Exclusion criteria is relevant to a study and I strongly suggest that is included in this manuscript.

The study protocol has been published, please provide the link if any. If there is no link to directly download the protocol, the citation will do.

Please ensure that your decision is justified on PLOS ONE’s publication criteria and not, for example, on novelty or perceived impact.

For Lab, Study and Registered Report Protocols: These article types are not expected to include results but may include pilot data.

==============================

Please submit your revised manuscript by Apr 15 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Ayi Vandi Kwaghe, D.V.M., M.V.Sc., P.G.D.E. Ph.D., MPH, FETP

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Study design and participants

“All categories of health workers” please, state the categories of health workers interviewed clearly.

“Eligible health workers”, inclusion criteria? Clearly state your inclusion and exclusion criteria for the study.

The study protocol has been published, please provide the link if any. If there is no link to directly download the protocol, the citation will do.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #3: Partly

Reviewer #4: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

Reviewer #4: I Don't Know

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4. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #4: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #3: No

Reviewer #4: Yes

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6. Review Comments to the Author

Reviewer #3: - Introduction is long

- Results need to be presented in more simplified and concise way

- Bias with questionnaire, No objective criteria

Reviewer #4: (No Response)

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Reviewer #3: Yes: Mohamed Saad Hashim

Reviewer #4: Yes: Mohammed Isa Bammami

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Attachment

Submitted filename: Plos One Covid paper review 2024.docx

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PLoS One. 2024 May 9;19(5):e0303172. doi: 10.1371/journal.pone.0303172.r004

Author response to Decision Letter 1

6 Mar 2024

RESPONSES TO COMMENTS BY REVIEWERS

Thank you for creating the time to review our manuscript and for your comments which have contributed to improve the manuscript.

Academic Editor

Study design and participants

1. Comment: “All categories of health workers” please, state the categories of health workers interviewed clearly. It’s okay to have it in Table 1 of your results but you need to categorically state this in your methods for researchers that will be reading your article. Please clearly state these categories in your methods.

Response: The individual categories of health workers have been stated in the methods section.

2. Comment: “Eligible health workers”, inclusion criteria? Clearly state your inclusion and exclusion criteria for the study. Does this mean that all health workers in those facilities that gave their verbal consent were eligible without taken into consideration of other factors that may affect the parameters such as confounders? Were there people that met the inclusion criteria but could not be included in the study due to some reasons? Exclusion criteria is relevant to a study and I strongly suggest that is included in this manuscript.

Response: Just as we said before, “eligibility criteria” (not “inclusion and exclusion criteria”) was used in the study design and during study implementation. Thus, it will not be appropriate to create “inclusion and exclusion criteria” at this stage. Such practice was informed by the STROBE reporting guidelines, relevant literature and our understanding that eligibility criteria could either be stated as “eligibility criteria” or separated into “inclusion and exclusion criteria”.

Please note:

(i) Potential confounders were already factored into the eligibility criteria (e.g living or working in Ebonyi state)

(ii) Because we used the “eligibility criteria” and not the “inclusion and exclusion criteria”, there was no separate inclusion criteria to be met, and exclusion criteria for excluding those who were included. All those living or working in Ebonyi state who gave consent were eligible.

(iii) If we were to use the “inclusion and exclusion criteria” format, the study population would perhaps be stated differently. Example:

(a) Study population: the health workers in Ebonyi state

(b) Inclusion criteria: clinical and non-clinical staff in public and private health care sectors such as: ……… (the individual categories of health workers could be listed here)

(iv) There are also examples of the “eligibility criteria” format in the literature (e.g https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0275234)

(v) The “inclusion and exclusion criteria” format can easily be restated or modified to the “eligibility criteria” format. Example: The “inclusion and exclusion criteria” is this paper (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0289825) is shown below:

Inclusion criteria:

“In order to participate in the study, participants must be at least 18 years old, have type 2 diabetes, be getting outpatient treatment, have fasting blood sugar (FBG) and glycated hemoglobin (HbA1C) tests, be taking diabetes medication, and have obtained consent.”

Exclusion criteria:

“Pregnant women and those who experienced an emergency requiring hospitalization are excluded.”

The above “inclusion and exclusion criteria” could be stated as “eligibility criteria” as below:

In order to participate in the study, participants must be at least 18 years old, have type 2 diabetes, be getting outpatient treatment, have fasting blood sugar (FBG) and glycated hemoglobin (HbA1C) tests, be taking diabetes medication, not be pregnant, not experienced an emergency requiring hospitalization, and have obtained consent.”

(vi) “Eligibility criteria” (not “inclusion and exclusion criteria”) was included in the STROBE Checklist and in the explanation and elaboration it was noted that eligibility criteria could also be presented as “inclusion and exclusion criteria” even though this separation was not always necessary or useful (https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0040297)

Reviewer

1. Comment: Title Clarity: The title is quite long and complex. Consider simplifying it for clarity while still capturing the essence of the study. For instance, "Experiences and Perceptions of COVID-19 and Vaccination Among Health Workers in Ebonyi State, Nigeria: A Cross-Sectional Analysis." Avoid Redundancies: The title repeats "COVID-19" twice, which could be streamlined for brevity.

Response: The title has been modified to reduce the length as we deem appropriate, to maintain consistency with our study concepts. Please note that the study explored experiences and perceptions/expectations about three main factors: COVID-19, COVID-19 vaccination (or vaccine), and COVID-19 vaccination process. These three factors were distinctly assessed and presented in the paper. The title was initially framed to capture these factors.

The suggested title is not acceptable to us because it does not clearly reflect our study concepts. “COVID-19” and “COVID-19 vaccination” are distinct and have different meaning and both have to be captured by the title. There is no recognized research guidelines/recommendations that a word should only appear once in a research title and examples of titles with a word appearing multiple (two or more) times is common in the scientific literature. What is more important is the overall meaning of the title taken as a whole (read and understood as a whole) and not the number of times a word appear.

2. Comment: It would be nice if you highlighted the implications of your findings in the abstract.

Response: The implications are the conclusions which are already stated. However, the conclusions have been modified as appropriate.

3. Comment: Some sentences are lengthy and could be made more concise. Shorter, clearer sentences would improve readability.

4. Comment: Page 3, Paragraph 1, Lines 60-61: The sentence beginning "Despite the successes recorded..." is quite long and complex. It could be broken down into shorter sentences for better readability.

Response: The first paragraph has been revised in line with new literature and some sentences have been reframed or broken into two to reduce their length. The main concepts investigated were variables with long names and this contributed to the length of sentences.

5. Comment: Page 3, Paragraph 2, Lines 72-73: The phrase "One of the factors sustaining..." is a bit vague. It might be helpful to specify which particular control measures are being referred to, and how they directly relate to the pandemic's management.

Response: The statement was based on the information in the cited reference material and it was modified to the current form in line with the comment of the Academic Editor during the first revision. We understand that it is clear as stated.

6. Comment: Limitations of Methodology: While some limitations are inherent in the study design (like sampling method), it would be helpful to discuss these limitations more explicitly. This includes addressing the potential biases and constraints that might affect the interpretation of the findings.

7. Comment: Study Design and Participants: The study is described as an analytical cross-sectional survey among health workers in Ebonyi State. The inclusion of both clinical and non-clinical staff is commendable for a comprehensive understanding. However, the use of convenience and snowballing sampling techniques might limit the generalizability of the findings. It’s important to discuss how this sampling approach may influence the results.

Response: We have already stated that selection bias from the sampling approach was a limitation (in addition to the other limitations) under “limitation” in the discussion section. We did not think there was much to discuss regarding the selection bias or that it was necessary to do so. The implication of the selection bias is obvious and well known. However, the statement has been modified and the implication added.

8. Comment: Data Collection Process: The use of a structured electronic questionnaire, distributed via WhatsApp and KoBoCollect, is innovative and suitable for the current digital age. However, there might be a need to elaborate on how the questionnaire was developed and validated to ensure it accurately captures the required information.

Response: Some statements have been added regarding questionnaire design and validation (lines 136–139) but the details are in the cited study protocol.

9. Comment: Statistical Analysis: The manuscript mentions the use of descriptive statistics, bivariate, and multivariate generalized linear models for data analysis. It would be beneficial to provide more details about the variables included in the models and the rationale for choosing these specific statistical methods.

Response: It is stated that all the independent factors were added to the model in the adjusted analysis. Please note that these independent factors are already listed in a preceding paragraph (the first paragraph under the “data management and statistical analyses” section. It will be an unnecessary repetition to list these factors again when talking about adjusted analyses (because all of them were inputed in the model as already stated).

10. Comment: Limitations of Data: Acknowledge any limitations inherent in your data, such as those arising from the sampling method or response biases.

Response: Identified limitations have already been stated in the discussion section.

11. Comment: Discussion of Key Findings: Briefly interpret the significance of these findings in the context of your research objectives.

Response: We understand that this has already been done.

PLoS One. doi: 10.1371/journal.pone.0303172.r005

Decision Letter 2

Ayi Vandi Kwaghe

22 Apr 2024

COVID-19 and COVID-19 vaccination experiences and perceptions among health workers during the pandemic in Ebonyi state, Nigeria: an analytical cross-sectional study

PONE-D-23-24420R2

Dear Dr. Omale,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Ayi Vandi Kwaghe, D.V.M., M.V.Sc., P.G.D.E. Ph.D., MPH, FETP

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #3: Yes

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

Reviewer #4: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #3: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Reviewer #3: The discussion is long. It needs to be considered and targeted. The tables need to be more simplified.

Reviewer #4: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: Yes: Mohamed Saad Hashim

Reviewer #4: Yes: Mohammed Isa Bammami

**********

PLoS One. doi: 10.1371/journal.pone.0303172.r006

Acceptance letter

Ayi Vandi Kwaghe

26 Apr 2024

PONE-D-23-24420R2

PLOS ONE

Dear Dr. Omale,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

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If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps.

Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Ayi Vandi Kwaghe

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Appendix

(DOCX)

pone.0303172.s001.docx^{(80.3KB, docx)}

S1 Dataset

(XLSX)

pone.0303172.s002.xlsx^{(1.4MB, xlsx)}

Attachment

Submitted filename: Response to Rviewers.docx

pone.0303172.s003.docx^{(43.1KB, docx)}

Attachment

Submitted filename: Plos One Covid paper review 2024.docx

pone.0303172.s004.docx^{(14.9KB, docx)}

Data Availability Statement

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

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PERMALINK

COVID-19 and COVID-19 vaccination experiences and perceptions among health workers during the pandemic in Ebonyi state, Nigeria: An analytical cross-sectional study

Ugwu I Omale

Cordis O Ikegwuonu

Glory E Nkwo

Ugochi I A Nwali

Olaedo O Nnachi

Okechukwu O Ukpabi

Ifeyinwa M Okeke

Richard L Ewah

Osarhiemen Iyare

Chidinma I Amuzie

Onyinyechukwu U Oka

Victor U Uduma

Azuka S Adeke

Roles

Abstract

Background

Methods

Results

Conclusions

Introduction

Methods

Study design and setting

Study participants and data collection

Data management and statistical analyses

Ethics statement

Results

Sociodemographic and background characteristics

Table 1. Sociodemographic and background characteristics of the 1276 study participants.

COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions

Table 2. COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions among the 1276 study participants.

Predictors of COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions

Table 3. Association between sociodemographic and background factors and the extent of COVID-19 experience and perception among the 1276 study participants.

Table 5. Association between sociodemographic and background factors and the COVID-19 vaccination process experience and perception level among the 1276 study participants.

Table 4. Association between sociodemographic and background factors and the COVID-19 vaccination expectation and perception level among the 1276 study participants.

Predictors of dichotomized (positive and non-positive) COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions

Discussion

Conclusions

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Ayi Vandi Kwaghe

Roles

Author response to Decision Letter 0

Decision Letter 1

Ayi Vandi Kwaghe

Roles

Author response to Decision Letter 1

Decision Letter 2

Ayi Vandi Kwaghe

Roles

Acceptance letter

Ayi Vandi Kwaghe

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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