Studying SARS-CoV-2 vaccine hesitancy among health professionals in Tunisia

The new corona virus disease (COVID-19) has drastically altered people's lives worldwide [1]. One year after declaring this new disease as a Public Health emergency, the number of deaths caused by this new disease exceeded two millions [2]. Measures such as lockdowns, social distancing, travel restrictions and mandatory mask wearing limited people’s freedom, triggered psychological issues, reduced the income of the disadvantaged groups and worsened the existing social and health inequalities [1, 3]. Until now, there is no specific treatment for this new disease. Nonetheless, several vaccines were developed in record time and were authorized for emergency use in a wide range of countries [4]. Indeed, speed vaccination of people is required not only to cut the spread of the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) but also to avoid the emergence and the spread of new variants threatening the efficacy of these vaccines [5]. However, tackling this pandemic requires substantial vaccination coverage rate [6]. This latter is conditioned by the acceptance of these vaccines especially by health professionals [7, 8]. In fact, being at the frontline of the war against the SARS-CoV-2 without immunization, expose them to a supplementary risk of contracting the SARS-CoV-2 and may increase the spread of COVID-19 among the users of healthcare facilities [8]. Indeed, according to a systematic review published in November 2020, the seroprevalence of SARS-CoV-2 antibodies among health professionals did not exceed 45.3% with an overall seroprevalence of 8.7% [9]. Otherwise, health professionals have a central role in promoting vaccination against the SARS-CoV-2 as they are considered trustworthy by the general public [10, 11]. Accordingly, the delay in accepting the SARS-CoV-2 vaccines among health professionals would slow down the attainment of the required vaccination coverage. The majority of studies led about hesitancy towards COVID-19 vaccination concerned the general population while fewer studies have focused on health professionals [7]. A scoping review, led mainly in developed countries, reported that the rates of hesitancy towards COVID-19 vaccination in healthcare workers vary from 4.3% to 72% [12]. Reasons behind the hesitancy towards the SARS-CoV-2 vaccination are also varied [13‐16]. North Africa is among the suggested regions where more studies should be led in order to address the scope of COVID-19 vaccine hesitancy [7]. In Tunisia, a North African country, the national vaccination program contributed with the concomitant demographic, social, and economic transitions in accelerating the epidemiological transition [17‐19]. Thanks to mandatory vaccination, this program succeeded in reducing the incidence rate of several communicable diseases such as tuberculosis, diphtheria, tetanus, pertussis, rubella, mumps and measles with national vaccination coverage rates around 90% [20‐22]. The current pandemic represents a new challenge for the Tunisian Health system. During the first wave (March–May, 2020), the prevalence of COVID-19 among health professionals was 14.8% [23]. During the second wave (which reached its peak in 20 January 2021), regarding the delay in obtaining the SARS-CoV-2 vaccines, the Tunisian government announced a lockdown between 14 and 17 January, the closure of schools between 14 and 24 January, the closure of markets and the delay of cultural manifestations between 18 and 24 January [24]. Meanwhile, Tunisian citizens were invited to register on a national website (evax.tn) in order to freely access to the SARS-Cov-2 vaccines when they will be available [25]. This online registration was launched in 15 January 2021 [26].

Estimating the prevalence and the predictors of hesitancy towards the upcoming SARS-CoV-2 vaccines among Tunisian health professionals would document the extent of this issue in Tunisia, identify most hesitant subgroup and guide local and international health authorities and organizations in their strategy to overcome this global health issue. In this context, the objective of the current study was to determine the prevalence and the predictors of SARS-CoV-2 vaccines hesitancy among a sample of Tunisian health professionals.

A total of 546 responses to the online questionnaire were obtained with 23 refusal and 523 acceptances. Among those who accepted to participate, 28 were not health professionals and two were not Tunisians. Accordingly, the retained participants accounted for 493.

The mean age of participants was 37.4 (± 9.5) years. Females represented 70.2% of participants. Medical Doctors, Dentists, Pharmacists and Paramedical professionals represented respectively 59.2%, 15.8%, 14.2% and 10.8% of participants. As regards the geographic location of their professional activities, 196 (39.8%), 188 (38.1%) and 105 (21.3%) were working respectively in the North, the Center and the South of Tunisia. Whereas, 82 (16.6%) participants reported daily direct contact with COVID-19 patients. More details about the sociodemographic characteristics are displayed in Table 1.

Focusing on the information sources about SARS-CoV-2, social media were the most consulted by participants followed by scientific journals and the television channels with the frequencies of 66.9%, 57.8% and 56% respectively while 39 (7.9%) participants used the national information website for Tunisian health professionals (SAUVE.tn). The other reported sources of information are detailed in Table 1.

Asking participants about their perceptions revealed that 327 (66.3%) were thinking that they have high or very high risk of SARS-CoV-2 infection (Table 1). Among dentists, this prevalence was 74.4% (Table 2). Nonetheless, 105 (21.3%) were thinking that they risk serious complications in case of infection (Table 1). This prevalence was the lowest among paramedical professionals (Table 2). On the other hand, 337 (68.4%) had concerns about the components of the upcoming vaccines. Otherwise, lack of information about the SARS-CoV-2 vaccines was reported by 403 (81.7%) of participants (Table 1).

Of the 493 respondents, 256 (51.9%; 95% CI_: 47.5–56.3)) reported SARS-CoV-2 vaccine hesitancy while 62 (12.6%; 95% CI: 9.7–15.5) were sure to refuse it and 175 (35.5%; 95% CI: 31.3–39.7) were sure to accept it when it will be available in Tunisia (Table 1). Refusal was the highest among paramedical professionals (Table 2).

Proportion of health professionals under the age of 40 years was significantly superior (72.3%) among those hesitating to get the vaccine than those not hesitating (59.5%) (p = 0.003). Similarly, females represented 74.6% of those who hesitate against 65.4% in those who do not with a p value of 0.047. Concerning the professional activity, working far from the North of Tunisia or in public sector, were significantly associated with more hesitancy towards the SARS-CoV2 vaccination (Table 3). However, having already contracted the COVID-19 was negatively associated with SARS-CoV2 vaccine hesitancy (0.4% among hesitating participants versus 12.2% among those not hesitating (p =  < 0.001)).

Perception of a lack of information about the SARS-CoV2 vaccination was positively associated with SARS-CoV2 vaccine hesitancy with a proportion of 85.9% among hesitant participants versus 77.2% in non-hesitant ones (p = 0.008). Use of social media was also positively associated with hesitancy towards the vaccination among participants (6.3% among hesitating participants versus 11% among those not; p = 0.043) contrary to the use of the national website of the Pasteur Institute or the national website for information about COVID-19 “Covid.tn” which were significantly associated with less hesitancy (Table 3).

Otherwise, thinking that the upcoming vaccines may contain harmful components was reported by 74.2% of hesitant professionals versus 62% among the rest of participants (p = 0.002). More details about the hesitancy towards the COVID-19 vaccination according to the individual characteristics of participants are displayed in Table 3.

Table 4 details the results of the binary logistic regression analysis for the factors related to SARS-CoV-2 vaccine hesitancy among participants. The magnitude of associations presented in “model 1” did not differ substantially from those in “model 2” from which the variable age was excluded. This indicate that the age is not an effect modifier. The variation of 20% between the values of the crude and the adjusted odds ratios for age may be due to a confounding effect. Similarly for “model 3” from which, the variable “Previous SARS-CoV-2 infection” was excluded to avoid an eventual convergence failure issue. Indeed, by excluding the variable “age,” the magnitude of associations did not differ substantially from those in “model 2” while working in the public sector and less frequent contact with COVID-19 patients were revealed to also predict more hesitancy among participants. On another note, the three models showed that working in the south of the country predicted the most hesitancy compared to those exercising in the central of Tunisia and with reference to those exercising in the north of the country. Concerns regarding the components of the upcoming vaccines represented another predictor of SARS-CoV-2 vaccine hesitancy with an adjusted OR comprised between 1.2 and 2.7. On the other hand, the use of the national website for information about COVID-19 (covid.tn) predicted less hesitancy with an adjusted OR of 0.6 [0.4–0.9].

To the best of our knowledge, this is the first Tunisian study that aimed at evaluating the acceptance of SARS-CoV-2 vaccines among all the categories of health professionals working in primary, secondary and tertiary care centers. It would provide a baseline reference for future evaluations. Our results would also serve for neighboring countries and other limited income countries in planning for their vaccination strategies.

Our study highlighted that between the 7^th and the 21^th of January 2021, 66.3% of Tunisian health professionals were thinking that they have high or very high risk of SARS-CoV-2 infection while 21.3% were thinking that they risk serious complications in case of infection. Acceptance rate of SARS-CoV-2 vaccine was 35.5% (95% CI: 31.3–39.7) whereas the prevalence of SARS-CoV-2 vaccine hesitancy was 51.9% (95% CI_: 47.5–56.3). Working far from the capital (in the south or in the central of Tunisia) and concerns about the vaccines components predicted more hesitancy among participants. In contrast, the use of the national COVID-19 information website predicted less hesitancy among them.

Despite the high rates of risk perception, only 35.5% of healthcare professionals in our sample were readily willing to get the SARS-CoV-2 vaccine. This low rate of vaccine acceptance is far away from the herd immunity targets [6]. It joins that in USA (36%) [15] and in Qatar (33.8%) [16]. However, it is lower than those in France (76,9%) [29], Italy (67%) [14] and Greece (78.5%) [30] and higher than those in several Arab countries [16]. Among paramedical participants, this rate was of 20.8%. Low vaccination acceptance rates were found among non-physician healthcare workers in other countries [31]. Otherwise, the hesitancy rate (51.9%) revealed by the current study was higher than that reported after an online opinion survey conducted among the same target population between the 10^th and the 20^th of January 2021 (33.6%). Nonetheless, this opinion survey showed a higher refusal rate of 23.5% [32]. The used sampling method during this online opinion survey was not reported. However, repartition of participants from the different fields of activities was similar to that observed in our study [32].

As reported in previous studies [33], participants were mostly females. The trend of feminization in the Tunisian health sector may explain somewhat this female predominance [34]. Analyzing hesitancy among participants according to the sex showed that females were less willing than males to uptake the SARS-CoV-2 vaccine. This result is harmonious with several other studies [12]. The higher male acceptance of vaccine may be due to a greater propensity for risk taking [35]. This also could be related to concerns among females about higher risks of induced autoimmune diseases or fertility problems as it was spread on social media [36, 37].

Older respondents were significantly less hesitant to uptake the SARS-COV-2 vaccine. However, having a chronic condition or allergy did not seem to contribute to this hesitancy among them. A recent scoping review reported that individuals of older age are more likely to accept COVID-19 vaccines [12]. This was explained by a perception of greater vulnerability to SARS-CoV-2 infection but also by higher education and greater experience in healthcare [12]. Indeed, among our participants, those who were trainees were more likely to be hesitant than those who have graduated.

Having its professional activity far from the north of the country (where is located the capital) predicted more hesitancy among participants. In line with this result, lower vaccination rates among deprived groups were observed in several surveys [15, 38, 39]. More efforts should be provided in the Tunisian underserved regions, especially in the south, in order to overcome regional disparities in terms of vaccination against SARS-CoV-2.

Professionals from private sector were significantly less hesitant to get the SARS-CoV-2 vaccine. This joins the results of a study led in Hong Kong [40]. This may be explained by economic reasons. In fact, in private sector; sick leave in case of COVID-19 episode is not regularly paid in Tunisia.

More frequent contact with COVID-19 patients was associated with less hesitancy towards the SARS-CoV-2 vaccine among participants. Indeed, a realistic risk perception allows the implementation of voluntary preventive behaviors [33]. On another note, having been previously infected by SARS-CoV-2 predicted less hesitancy among participants. Divergent results were reported regarding the association between previous COVID-19 infection and willingness to receive a SARS-CoV-2 vaccine [41‐43]. These divergent attitudes may be explained by the lack of knowledge about the duration of protective immunity after infection by this new virus [44].

Among participants, 81.7% reported lack of information about SARS-CoV-2 vaccines. Social media were the most used information source by them, which joins the results of an Egyptian study [45]. Lack of information and use of social media to be informed about SARS-CoV-2 vaccines were both significantly associated with more hesitancy towards these vaccines among participants. These results corroborate those of similar studies led in Egypt and Italia [11, 21] [14, 46]. Concerns about the vaccines components represented another predictor of SARS-CoV-2 vaccine hesitancy among participants. In fact, doubts regarding the SARS-CoV-2 vaccines safety among health professionals were reported in several countries such Italy [14], Democratic republic of Congo [39] and Egypt [45]. Differently, the use of the official national websites was significantly associated with less hesitancy rates among participants. Similar result was observed in Saudi Arabia [41]. Indeed, improved information on vaccines has been shown to increase vaccines’ acceptance [47].

Focusing on the vaccination campaign in Tunisia, we can note that although the launch of the online registration to get the vaccine since 15 January 2021 [25], the vaccination did not start before 13 March 2021. In fact, there were difficulties to obtain vaccines doses [48]. Health professionals represented the first priority group [26]. The concomitant communication plan included a first step of registration promotion during February 2021 with disinformation countering via mass media and social media. The second step began in March 2021. It aims to facilitate registration of people and to inform them about where and when they can beneficiate from the vaccine [26]. After one year of the onset of the vaccination campaign, proportion of vaccinated health professionals is still unavailable [25, 26, 49]. In addition, the incidence of COVID-19 among health professionals does not figure on the periodic national reports [25, 26, 49]. As of 7 March 2022, four reports were published (since September 2021) about the recorded side effects among the vaccinated people [50]. However, the content of these reports was not disseminated through the official website of the ministry of health [26] or the national vaccination portal [25].

SARS-CoV-2 vaccine scarcity in Tunisia and poor resources [51] should not discourage policy makers to implement an effective information campaign. Involving health professionals, especially Public Health specialists, in this campaign would increase confidence in the vaccines, as they are experts in prevention methods. Involving partners from the other sectors such as anthropologists, artists and national leaders is also recommended. Sharing updated information with health professionals during periodic sessions would encourage hesitant ones to uptake the vaccine. Especially, females, the youngest ones, paramedical professionals and those in the underserved regions. The content of these sessions should focus on the severity of COVID-19 episodes and the impact of adherence to self-protective behaviors [52]. To increase confidence in the vaccines, the broadcast messages should report the development methods and the protection mechanisms of the SARS-CoV2 vaccines. Organizing vaccination sessions in the occupational health centers would encourage these groups to uptake the vaccine. Facebook represent another way for disseminating valid messages and tackling misinformation about the vaccines, especially that it represents the most famous social media platform in Tunisia [16]. Engaging health care professionals in social media to counter the vaccines’ related misinformation would improve the vaccine acceptance among the other health professionals and the general population as well. In fact, the general population considers them trustworthy.

More solidarity at the international level is required for a global COVID-19 vaccine equity. Otherwise, we risk the emergence and the spread of new variants of the SARS-CoV-2 which could threaten vaccinated and not vaccinated people worldwide.

Results of the current study should be interpreted with taking into account some limitations. Firstly, the cross sectional nature of the study did not allow to report causal relationships but only statistical associations. Besides, random sampling was not possible as no lists of national or regional health professionals were available. However, the required sample size was reached. Moreover, although that Public Health professionals were not represented in our sample because of their reduced number in Tunisia, the main categories of the health professionals were represented. Finally, attitudes and perceptions were self-reported by participants, which might lead to a social desirability bias. Nonetheless, data were collected anonymously and participation was voluntary.

An effective national information campaign is required to reassure the Tunisian health professionals regarding the safety of COVID-19 vaccines. Females, the youngest ones, paramedical professionals and those in the underserved regions deserve more attention. Social media would represent a cost effective tool for this campaign.