Hesitancy towards the COVID-19 vaccine among health care practitioners in the Kingdom of Saudi Arabia: a cross-sectional study

Introduction

The coronavirus disease 2019 (COVID-19) pandemic is a major public health issue worldwide. Up to November of 2022, 628 million confirmed cases and over six million deaths were registered worldwide.¹ This led to development of vaccines in an expected way. For example, in less than 12 months since the World Health Organization (WHO) declared the outbreak, several numbers of COVID-19 vaccines have already been approved and deployed mostly in developed countries since January 2021. In the Kingdom of Saudi Arabia (KSA), four vaccines have been approved by the health regulatory bodies (i.e., Oxford-AstraZeneca, Johnson & Johnson’s Janssen, Moderna, and Pfizer/BioNTech),² with a priority to vaccinate health care practitioners (HCPs) alongside other groups who are at a higher risk of COVID-19.³

HCPs are more likely to be infected by COVID-19 virus as they are in direct contact with infected patients. In a study by Nguyen et al. (2020) conducted on more than 200,000 HCPs, they found that HCPs at the frontline of care had a threefold increased risk of being infected with COVID-19.⁴ Asua and colleagues (2021) reported that COVID-19 infection rates among HCPs have ranged between 10% and 20% in Spain.⁵ In KSA, Barry et al. (2021) concluded that almost 13% of the HCPs have been infected with COVID-19.⁶ Because of the difficulty in applying social distancing in health care facilities, HCPs might spread the virus within themselves and in between patients. This situation could be worsened in case of the shortages of personal protection equipment.^7,8

Multiple countries have decided to initially provide COVID-19 vaccines to the most vulnerable groups including HCPs.^5,6,9–11 Achieving a high vaccination coverage level among HCPs will ensure the presence of an adequate number of protected workforces to deal with the pandemic more effectively and efficiently.¹² Prioritizing HCPs to receive COVID-19 vaccines is essential to keep the health care system running, protect very sick individuals during the pandemic, and to ensure the provision of the vaccines to be running for the public.¹⁰

Hesitancy to accept the newly developed vaccines is a well-known public health challenge,¹³ which might be exaggerated after documenting rare thromboembolic events among vaccinated individuals.¹⁴

Also, Shekhar et al. (2021) reported that concerns about vaccine efficacy, adverse effects, and rapidity of the production were the most important factors affecting hesitancy to receive the COVID-19 vaccine.¹⁵ Hesitancy to accept COVID-19 vaccines could also be complicated by misinformation, conspiracy beliefs, and theories that the virus is man-made and used for population control.^16,17

Several studies have sought to determine the level of willingness to receive COVID-19 vaccines as well as the factors influencing vaccine acceptance. COVID-19 vaccine acceptance levels were varied between studies conducted in different countries. Levels of vaccine acceptance in these studies were reported to be 63% in Hong Kong as of April 2020,¹⁸ 77% in France as of July 2020,¹⁹ 72% in France and French-speaking Belgium and Quebec as of November 2020,²⁰ 81% in Canada as of December 2020.²¹ To examine this further, a study conducted in KSA prior to the development of the vaccines demonstrated that only 50% of the HCPs were willing to receive the vaccine.²² Moreover, the acceptance level to receive COVID-19 vaccines among HCPs in KSA (as of November 2020) was reported to be 70%.⁶

There has been no research conducted after the approval of the COVID-19 vaccines in KSA. Therefore, this study aimed to measure hesitancy and willingness toward COVID-19 vaccines among HCPs in Saudi Arabia.

Methods

Results

Out of 776 participants who started the survey, 505 (65.1%) completed it and were included in the analysis. The remaining 271 did not complete the survey fully; therefore, they were excluded. The demographical characteristics of the participants are presented in Table 1. Among 505 HCPs who completed the survey, 47 (9.3%) either said “no” to receive the vaccine [20 (4%)] or were hesitant to receive it [27 (5.3%)]. Of the total number of the HCPs, 376 (74.5%) had already received the COVID-19 vaccine, and 48 (9.5%) were registered to receive it. Out of the 34 participants (6.7%) who wanted to receive the vaccine, the majority of them [20 (59%)] preferred the Pfizer-BioNTech vaccine because they believed it had fewer side effects and was more effective than AstraZeneca vaccine.

The associations between the demographic characteristics of the HCPs and their willingness to receive COVID-19 vaccines is presented in Table 2. Female HCPs were less willing to receive the vaccine (47.3%) compared to male HCPs. However, no statistically significant association was found between gender and willingness to receive the vaccine (p = 0.26). Significant association was only found between having excellent or good health condition and the willingness to receive the COVID-19 vaccine (p = 0.03).

Table 3 presents the average scores and standard deviations of HCPs who were willing to receive the COVID-19 vaccines using the VHS. HCPs who were willing to receive the vaccines were found to agree that the vaccine is important to health (2.67 ± 1.17, p < 0.001) and it will be effective in preventing the infection (2.75 ± 1.104, p < 0.001). HCPs who were not willing to receive the vaccines were more convinced that they are in good health, and the pandemic is just elevated, therefore, they don’t need to be vaccinated (4.10 ± 1.08, p < 0.001 and 4.22 ± 0.96, p < 0.001). In addition, HCPs who were not willing to receive the vaccines have doubts about the safety of COVID-19 vaccines (3.38 ± 1.16, p < 0.001) and were worried about the side effects of the vaccines (2.91 ± 1.08, p < 0.001). The difference between the VHS scores were significantly different throughout the VHS items (see Table 3).

Figure 1 shows the reasons of accepting to receive the COVID-19 vaccine; wanting to protect self and others from getting the infection was the main reason (24%). Figure 2, however, shows the reasons for not accepting COVID-19 vaccines. Most of the HCPs were lacking the trust in this vaccine because it is new (20%).

Figure 1. The main reasons of accepting to receive the COVID-19 vaccine.

Figure 2. The main reasons for not accepting COVID-19 vaccines.

Discussion

The main finding of this study was that 9.3% of the HCPs either didn’t want to receive the vaccine or were hesitant to receive it. This indicates that the vaccine hesitancy among the HCPs in our sample from Saudi Arabia may not be of a serious issue. Although there are few studies assessed the hesitancy toward vaccination, our results are consistent with the current literature.^25,26 Civelek et al. (2021) found that 68.4% of physicians in Turkey were willing to get vaccinated.²⁵ Robertson et al. (2021) reported that 82% of UK population were willing to get vaccinated.²⁶ However, willingness level to receive the vaccine may differ between countries and communities. In a recent study, sampled from 19 countries with more than 13,000 participants, the acceptance of COVID-19 vaccines ranged from 54.8% in Russia to 88.6% in China.²⁷ Data collected from Saudi Arabia before the vaccination campaign showed that the COVID-19 vaccines’ acceptance level among the population was 64.7%.²⁸

The results of this study showed that 76.6% of the Saudi HCPs were willing to receive COVID-19 vaccines. A previous study on HCPs in Saudi Arabia, prior to the vaccination campaign, showed that the COVID-19 vaccines’ acceptance level was reported to be 50.5%.²² This surge in the acceptancy level by more than 26% following the vaccine campaign can be attributed to several factors, but one major factor was that the government of Saudi Arabia prohibited unvaccinated people from traveling, entering private establishments and government buildings, or performing Hajj and Umrah.²⁹ However, our results showed that 23% of HCPs were hesitant to receive the vaccine. Not receiving the vaccine will place HCPs at higher risk of getting infected and spread the infection to their patients and other HCPs. Compliance with public safety measures (social distancing, face mask, and hygiene) could help to reduce the transmission of the virus.⁸ However, the increased demand on health care services during the pandemic with the severe shortages in HCPs make it very challenging to comply with those measures. This is complicated by to the difficulty in implementing social distancing in health care facility and the shortages in personal protective equipment.⁸

Our study showed that the majority of those who agreed to receive the vaccine were young, up to 24 years. This result is similar to a study conducted by Al-Mohaithef et al. (2020) in which they found that the majority of those who agree to receive the vaccine were from the age group between 26 to 35.²⁸ Qattan et al. in 2021 measured Saudi HCPs’ acceptance of the COVID-19 vaccine and found that the majority of those who agreed to receive the vaccine were from the age group between 30 to 39 years.²² However, several other studies showed that the willingness to receive COVID-19 vaccines were higher in old ages (50 years and above) for HCPs,¹⁵ and for the general population.³⁰ One justification for this contradiction between Saudi HCPs and others can be attributed to the youth population of Saudi Arabia compared to the western countries. In total, 37% of the Saudi population are between the age of 15 to 34 years.

Interestingly, our study results showed that the factors that influenced the HCPs willingness to receive the vaccine were:

These findings support the conclusions of several previous studies^31–33 that showed health issues such as mental illness, chronic health problems or physical health problems may lead to both vulnerability and inequality.³¹ Therefore, even if the vaccines uptake falls short in some high-risk groups, a trivial increase in vaccines uptake will have significant health benefits.³³

We also determined the reasons for accepting or rejecting to receive COVID-19 vaccines as reported by the HCPs. Our findings contradict the results from Verger et al. (2021) about the safety concerns of COVID-19 vaccines.²⁰ Verger and colleagues concluded that concerns about the safety of the COVID-19 vaccines was, by far, the most important factor for hesitancy or reluctance and for moderate acceptance.²⁰ Contrarily, Shekhar et al. (2021) found that most HCPs (86%) believe that the COVID-19 vaccine is safe.¹⁵ However, Qattan et al. (2021) study showed that 16.82% of the HCPs in KSA have safety and efficacy concerns about COVID-19 vaccines, and 26.73% have fear of the adverse side effects of the vaccines.²² Even though our study was conducted after the beginning of the vaccine campaigns, we found that 21% of the HCPs doubt the safety of the vaccines, and 39.5% were worried about the possible side effects of COVID-19 vaccines. The increased percentage of HCPs with concerns regarding the COVID-19 vaccines in our study could be explained by the recent reports about the possible vaccine’s adverse effects, such as the formation of blood clots in large arteries.³⁴

Previous studies suggested that believing in the conspiracy theory behind COVID-19 was a factor of rejection.^22,35,36 This is similar to our findings which suggested that 5% of the HCPs rejected the vaccine because they believed rumors about the vaccines such as the “chip theory”. Although 5% seems low, it may reflect the fact that our population only included HCPs and this percentage could rise if we conducted the study in the general population and amongst those who do not trust any source of information on COVID-19 vaccines. However, Qattan et al. reported that only 0.6% of the HCPs believed that COVID-19 does not exists.²²

Limitations

This study has some limitations. First, although the sample size in our study was objectively determined, we used a snowball sampling method to distribute the survey link among HCPs in the KSA. This method may have caused a selection bias since most of our sample were from the eastern province of KSA. Therefore, our sample may not be representative of all HCPs in KSA, which can limit the generalizability of the findings. In addition, this was a cross-sectional study. Therefore, we could not draw causal relationships between the factors and COVID-19 vaccine acceptance. Finally, the study's questionnaire was published online in the English language only, which produced a selection bias favoring English-literate HCPs only and those who have Internet connections.

Future studies

Despite the limitations, our study was able to explore some of the unknown factors associated with COVID-19 vaccine acceptance and rejection which were not explored in previous studies. Also, given the representative sample size across KSA, the findings comprehensively demonstrated health care practitioners’ intention to uptake the COVID-19 vaccine. Future research is therefore needed to assess this study’s findings and to examine additional challenges around vaccinations in the Saudi population. Further investigations of the vaccine’s safety awareness and promotion strategies to encourage individuals to get the vaccine, as well as exploring key barriers towards receiving the COVID-19 vaccination are needed.

Conclusion

Our findings have shown that hesitancy toward receiving COVID-19 vaccines among HCPs in Saudi Arabia is limited and therefore may not be of a serious issue. Also, the outcomes of this study help to understand factors that lead to vaccine hesitancy in Saudi Arabia and help public health authorities to design targeted health education interventions aiming to increase vaccine’s acceptance and uptake.

Data availability