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The Egyptian Journal of Internal Medicine
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Frequency and determinants of acceptance of COVID-19 vaccine booster dose among health care providers: a cross-sectional study

The Egyptian Journal of Internal Medicine volume 36, Article number: 107 (2024) Cite this article

Abstract

Background

As the COVID-19 virus spreads, it has new opportunities to change, and new variants of the virus are expected to occur. Health care workers (HCWs) are potential victims of the disease and spread it. They are more vulnerable to infection due to their occupational and nonoccupational exposure. The aim of this study was to identify the frequency and determinants of the acceptance of health care providers to receive the booster dose of COVID-19 vaccine.

Methods

An online questionnaire was used to collect data by the Egyptian HCWs. The questionnaire had four sections: the first section included the participants’ sociodemographic data, the second section included data on the participants’ previous COVID-19 infection status, the third section was on COVID-19 vaccine-related information, and the fourth section evaluated the intention to take the booster dose, causes of acceptance or refusal, and any suggestions to combat COVID-19.

Results

A total of 413 HCWs completed the questionnaire. Females represented 79.9%, and 37.3% had direct contact with COVID-19 patients, and 61.7% had previous infection. The vast majority (94.2%) received COVID-19 vaccine, 52.1% agreed to receive the booster dose, while 47.9% refused. The most common reason to receive booster dose was for increasing protection against new variants (48.4%) and lowering rate of severe illness and hospitalization (41.4%). Male gender and previous COVID-19 vaccination were the main determining factors of acceptance to receive booster doses.

Conclusion

Acceptance of COVID-19 booster vaccination was relatively inadequate among the HCWs. Male gender and previous COVID-19 vaccination were determinants of acceptance.

Background

Following the first emergency use authorization for COVID-19 vaccine by the Food and Drug Administration (FDA), priority of the vaccine was given for health care workers and medical students [1]. FDA allowed for a COVID-19 vaccine booster dose following a primary mRNA COVID-19 vaccination those aged more than18 years who are at increased risk for risk of exposure or serious complications of COVID-19 and recipients aged more than 18 years of Janssen vaccine [2]. The use of the third booster dose of the same vaccine after the first two doses (homologous boosting) and the use of a different vaccine as a booster (heterologous boosting) have both been the subject of numerous studies. The major immune response occurred when a booster of an mRNA vaccine was used after a primary dose of either an mRNA vaccine or an adenovirus vector vaccine. Nearly all combinations of initial course and booster vaccines provided a marked enhancement of the immune response [3].

By the beginning of the year 2021, Egypt began COVID-19 vaccination by following a global strategy to prioritize health care workers (HCWs) followed by older people. Later, the vaccine was available for free for all population by Ministry of Health and Population (MOHP). Data on the coverage and public opinion of COVID-19 vaccines were recorded by MOHP through the national disease surveillance (NEDSS). In this survey, 48.3% were found to received COVID-19 vaccine, and 44.3% were fully vaccinated which indicated lower vaccination coverage compared to the World Health Organization (WHO) 70% target [4]. The Egyptian government made sure that the vaccine is affordable and accessible to the population.

Understanding the factors which could influence vaccine acceptance is crucial to improve this important aspect of COVID-19 prevention [5]. However, vaccine hesitancy is still an issue. Hesitancy among families and their children exists especially in remote areas [6]. Vaccine hesitancy is defined as a delay in acceptance or denial of vaccination regardless of the accessibility of vaccines. Vaccine hesitancy is complicated with great difference across time, locality, and type of vaccine [7].

Factors which affect vaccine hesitancy could include sociodemographic factors, risk awareness, cost, considerations of adverse effects, and others, which reduce the willingness among various groups to vaccinate [8]. HCWs are susceptible to this extremely contagious virus because of occupational exposure. Appropriate vaccinations are of great help to lower viral transmission rates and subsequent illnesses particularly in cases of outbreaks [9, 10]. Ensuring the protection of HCWs is a crucial element as a strategy to combat COVID-19. Previous pre-COVID-19 studies have examined HCW vaccine hesitancy, with a focus on seasonal influenza vaccination [11, 12].

HCWs concerns are consistent with those observed for the general population, but the rapid development of COVID-19 vaccines was associated with a different pattern of hesitancy. Despite extensive medical training, HCWs still experience the same emotional dilemmas like the general population [13]. Little is known about the attitude of heath care providers toward the booster dose of COVID-19 vaccine in Egypt.

Methods

The aim of the study was to identify the frequency and determinants of acceptance of health care providers to receive the booster dose of COVID-19 vaccine.

In this cross-sectional study, Egyptian health care providers aged > 18 years were included. The participants were recruited using a convenient snowball sampling method, sending out Google Forms links to the institutional groups of HCWs. The sample size was calculated using OpenEpi version 6 considering the proportion of willingness to take the third dose of COVID vaccination as 50% and a confidence level 95%. The level of significance was set at less than 0.05. Accordingly, the minimum sample size was estimated to be 384.

An online self-administered questionnaire in Arabic language composed of four sections in the form of multiple choices was distributed using the Google Forms platform via e-mail and other social media in the period between (April 2023-September 2023). The total response time was approximately 10 min. The first section included the sociodemographic data, such as age, sex, marital status, residence, occupation, special habits, and comorbidity. The second section included data on the COVID-19 infection status of the participants such as the presence of or contact with COVID-19 patients in the workplace, previous COVID-19 infection, severity of infection or hospitalization, and the presence of infected or vaccinated family member. The third section included data related to COVID-19 vaccine such as previous vaccination, receiving the full vaccine doses, the type of vaccine, motivation of vaccination, development of vaccine adverse events, and the extent to which the participants consider the vaccine is safe. The fourth section evaluated the intention to take the booster dose, causes of acceptance or refusal, and any further suggestions by the health care providers to combat COVID-19. The questionnaire was validated, and Cronbach’s alpha coefficient was 0.70 with good internal validity and reliability.

Data was analyzed using SPSS software version 21. Frequency counts, percentage, and mean ± standard deviation were used to analyze demographic data. Qualitative data analysis was done using chi-square test. The significance level was set at p-value < 0.05.

Results

Table 1 presents the personal characteristics of the studied HCWs. The participants’ mean age was 36.4 years with the range of 20–70 years. Nearly 80% were females, three quarters were married, 77% were urban residents, and 16.7% had comorbid conditions. Data on COVID-19 infection status is shown in Table 2, more than half of the participants had COVID-19 patients at their workplaces, and 37.3% of them were in direct contact with COVID-19 patients. About two-thirds (61.7%) of the studied HCWs reported that they got COVID-19 infection, but 48.2% confirmed their infection by the investigation using PCR test. Regarding the severity of the infection, 31.7% had mild disease, and only 3.5% of the cases needed hospital admission.

Table 1 Sociodemographic characteristics of the studied health care workers
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Table 2 COVID-19 infection status of the studied health care workers
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Table 3 shows the data regarding COVID-19 vaccine and illustrates that 94.2% of the participants received the vaccine against COVID-19. The reasons for taking the vaccine were as follows: for self-protection (43.6%), protect their family and friends (38.7%), or required by workplace (33.2%). On the other hand, 19.7% of the health workers did not receive the vaccine because they were busy and have no time to get vaccinated. The long waiting list before receiving the vaccine and medical causes was reported by 15.4% and 8.2% as reasons for not getting vaccinated. Adverse effects were reported by 60.7% of the participants, mainly in the form of fatigue (74.6%), muscular ache (64.8%), and fever (58.9%). The common types of COVID-19 vaccines received by the studied group were AstraZeneca (37.3%), Sinopharm (24.7%), Johnson (16.7%), and Sinovac (11.9%) (Fig. 1).

Table 3 COVID-19 vaccine-related information among health care workers
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Fig. 1
figure 1

Types of COVID-19 vaccines received by the studied group

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Attitude toward receiving COVID-19 booster in Table 4 shows that 52.1% of the studied HCWs agreed to receive COVID-19 booster dose, while 47.9% of the respondents did not agree. The most common reasons to receive it were increasing their protection against COVID-19 new variants (48.4%) and lowering rate of severe illness and hospitalization (41.4%). About 44.1% will advise their patients or relatives to take the booster vaccine.

Table 4 Determinants of acceptance of receiving COVID-19 booster dose among health care workers
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Figure 2 shows the suggestions of the studied HCWs to fight COVID-19 infection which were the availability of vaccines with long-lasting immunity (42.4%), the presence of curative drugs (27.6%), conducting clinical trials on the vaccinated persons (21.5%), and herd immunity (20.6%). Table 5 reveals the determinants of acceptance of COVID-19 vaccine booster dose and shows that male gender and previous vaccination against COVID-19 were the factors of a statistically significant difference.

Fig. 2
figure 2

The suggestion of the studied health care workers to combat COVID-19 infection

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Table 5 Factors associated with acceptance of receiving COVID-19 booster dose among the studied health care workers
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Discussion

Health care workers (HCWs) are highly vulnerable to COVID-19 because of their line of work. They run the risk of getting sick themselves and infecting susceptible patients. These factors led to the obligation of health professionals to receive COVID-19 vaccine [14].

The results of this study showed that 61.7% of the studied HCWs reported that they had COVID-19 infection because of the occupational exposure. In the current study, 94.2% of HCWs were vaccinated against COVID-19, but 10.2% received only the first dose of the vaccine. These findings are consistent with Salah et al. multicenter study, which revealed that 96.7% of HCWs had been vaccinated against COVID-19 [15]. This could be due to the knowledge of the COVID-19 infection drawbacks and practice of HCWs. There is a vast global database on COVID-19 vaccines safety because many billions of the doses had been distributed worldwide [16]. Hence, more than half of the participants in the present study believed in the vaccine safety.

This study showed that more than half of HCWs would accept receiving COVID-19 booster vaccine when recommended. Similarly, Arshad et al. study showed that 52.1% agreed to take the COVID-19 vaccine booster dose, while 34.7% refused and 24.2% hesitated to take it. Concerns about the safety and efficacy of the booster dose were the main reason [17]. On the other hand, another study in Poland found that about three-quarter of the health care participants accept to receive COVID-19 booster dose, 7.9% had hesitancy, and 17.6% expressed their rejection [18]. In Saudi Arabia, 71.1% of HCWs showed willingness to receive a booster dose [19]. In a recent study in Egypt and Kingdom of Bahrain, 46.1% of the physicians were not willing to take the booster doses [15].

The majority of HCWs in the current study received the booster vaccine which imply positive attitude toward the COVID-19 booster vaccine. This could result from the beliefs of the HCWs in the capability of the protective effect of vaccination including the new variants an answered in the questionnaire. This relatively good vaccination acceptance rate among HCWs may have positive effect on the vaccination compliance of other persons. In previous Egyptian studies, lower acceptance rates among HCWs to receive the COVID-19 vaccine were encountered, and the main reasons beyond vaccine refusal were concerns regarding vaccine efficacy and safety [20, 21]. The result is in concordance with the global pooled acceptance rate of COVID-19 vaccine among HCWs which was 55% [22]. In a recent Indian study, the uptake of the primary COVID-19 vaccine dose was adequate, while receiving booster doses was inadequate, and the main reason for refusal was the belief that two doses of the vaccine are sufficient to provide disease protection [23].

However, in our study, about 48% of the participants showed unwillingness to receive the booster dose of the vaccine because of some factors such as fear from the long-term vaccine adverse effects, lack of sufficient clinical trials on COVID-19 vaccine, and less virulence of SARS-CoV-2 than before and the generation of new variants. These factors led to respondents’ hesitancy toward the vaccine.

Among the factors that were found to be significantly associated with acceptance for receiving COVID-19 booster dose in the current study was male sex. In another study, females were also less liable to receive vaccinations than males which could be explained by the general negative perception of women of the pharmaceutical and medical products [24]. Sallam and his team found that the studied public in Jordan and Kuwait believed that COVID-19 vaccine could cause infertility [25]. Previous studies showed that female HCWs had lower rates of COVID-19 vaccination willingness and uptake [21, 22].

Another factor in this study which was associated with acceptance of booster vaccine was previous vaccination against COVID-19. This is in concordance with a recent Chinese study which found that HCWs who received three doses of COVID-19 vaccine were less likely to be hesitant compared to those who had not received it [26]. Meanwhile, a meta-analysis showed that the previous COVID-19 infection correlated with a lower intention to receive the booster dose but higher level of uptake of the booster dose [24]. On the other hand, hesitancy toward booster doses was reported in 2.8% to 26% of HCWs who had taken primary doses of COVID-19 vaccine [27]. Recently, among nurses, 30.9% were hesitant to receive a second booster dose or a new vaccine. Increase of the hygiene measures, fear of a booster dose, and low trust in the vaccine were associated with increased hesitancy [28].

Postvaccination adverse reactions were a key factor influencing the acceptance of the booster shot. In this study, there was no significant difference between the participants who suffered from the adverse effects of the vaccine and those who did not. On the other hand, another study investigated the impact of decision regret and the consequences of postvaccination adverse reactions on the hesitancy to undertake booster dose in Pakistan and found that participants who had negative attitudes to vaccinations were less likely to accept the booster dose than those who did not [29]. Fear of vaccine adverse effects was one of the main barriers for the acceptance in another study [18].

This study had some limitations. One of them is the use of an online survey which was completed by HCWs who agreed to participate in this study. Therefore, the questionnaire was completed by HCWs who had access to the questionnaire and those who are interested in the subject. So, this study is susceptible to selective and reporting bias and could have limited generalizability to the population. Hence, future studies and a deeper understanding of this issue should benefit from these findings.

Conclusions

Acceptance of COVID-19 booster vaccine was relatively inadequate among the studied Egyptian HCWs. Understanding the rationale of the intention to acquire booster doses among HCW is crucial to enhance the immunization by the booster doses in the public. As HCWs are in direct contact with them, this could help to combat the pandemic.

Data availability

The data sets generated and/or analyzed during the current study are not publicly available due to confidentiality of the participants but are available from the corresponding author on reasonable request.

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Acknowledgements

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Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or nonprofit sectors.

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Authors and Affiliations

  1. Department of Gastroenterology, Hepatology, and Infectious Diseases, Assiut Liver Center, Ministry of Health and Population, Assiut, Egypt

    Nagat Ibrahim

  2. Department of Public Health and Community Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt

    Ekram M. Abdel Khalek

  3. Department of Hepatology, Gastroenterology, and Infectious Diseases, Faculty of Medicine, Al-Azhar University, Assiut, Egypt

    Muhammad Abdel-Gawad

  4. Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, Assiut University, Assiut, Egypt

    Haidi Karam-Allah Ramadan

  5. Department of Clinical Pharmacy, Ministry of Health and Population, Cairo, Egypt

    Adel Gaafer

  6. Department of Rheumatology and Rehabilitation, Mataria Teaching Hospital, Cairo, Egypt

    Soha Sayed Shaaban

  7. Department of Clinical Pharmacy, Ministry of Health and Population, Tanta, Egypt

    Amany Saeid Eltantawy

  8. Department of Clinical Pharmacy, Mansoura Specialized Hospital, Mansoura, Egypt

    Dalia El-Mowafy

  9. Department of Clinical Pharmacy, Qalioub Specialized Hospital, Qalioubia, Egypt

    Mona Ahmed Mohammed Abdelmgeid

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  1. Nagat Ibrahim
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Contributions

N.I: conceptualization, M.A and A.G: study design, S.S, A.S, M.A: collecting data, writing the original draft, E.M and D.E: data analysis, N.I, H.K, A.S, D.E: writing and editing the final draft. All authors reviewed the manuscript.

Corresponding author

Correspondence to Haidi Karam-Allah Ramadan.

Ethics declarations

Ethics approval and consent to participate

The study was carried out in compliance with the laws on ethical standards and privacy protection in accordance with the Declaration of Helsinki. The Research Ethics Committee, Central Directorate of Research and Health Development, Ministry of Health, in Egypt approved the study (IRB No.: 8–2022/8).

An informed written consent was obtained as the HCWs were asked to confirm their agreement with the information provided and their willingness to participate online. An introductory note was enclosed along with the questionnaire, explaining the study’s objectives and assured the anonymity and the confidentiality of the respondents.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Ibrahim, N., Abdel Khalek, E.M., Abdel-Gawad, M. et al. Frequency and determinants of acceptance of COVID-19 vaccine booster dose among health care providers: a cross-sectional study. Egypt J Intern Med 36, 107 (2024). https://doi.org/10.1186/s43162-024-00369-7

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