STRENGTHS AND LIMITATIONS OF THIS STUDY
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The main strengths of the study were a large sample size, and timeliness of the survey.
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Bias was reduced by increasing the sample size, using a defined target population, and making the survey as short as possible.
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The main limitation was sampling bias, because some healthcare workers could not access the online survey. Thus, the generalisability of the survey cannot be guaranteed.
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A small number of physician participants and a group of health workers had the most significant impact on the decision-making of the population.
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Because this was a web-based survey, we could not track information on non-responses.
Introduction
The COVID-19 is a major public health threat that has affected more than 220 countries worldwide.1 2 As of 15 June 2021, Nigeria had recorded 167 078 COVID-19 cases and 2117 COVID-19 related deaths out of 176 million cases and 3.8 million deaths recorded globally.1 2
Several public health measures, such as social distancing, wearing face masks, frequent hand washing, avoidance of crowded places, self-isolation and quarantine were instituted globally to curb the spread of the virus, save lives and flatten the epidemic curve. However, these measures were insufficient.3 Thus, there is an urgent need to establish herd immunity through vaccinations.4 5 The collaborative effort by the international scientific community have led to the rapid development of effective and safe vaccines against COVID-19.
Nigeria prioritised frontline healthcare workers (HCWs), elder statesmen and elderly people (>60 years) as the first recipients of the four million doses of the Oxford/AstraZeneca COVID-19 vaccine delivered to the country.6 Administration of the COVID-19 vaccination in Nigeria was challenging because of the lack of trust in vaccine safety and concerns about vaccine effectiveness, even among HCWs.3 7 HCWs are crucial to Nigeria’s primary healthcare system, as they provide reliable information about vaccines and vaccine-preventable diseases, especially at the foundational level.8 9 Hence, the attitude and acceptance of HCWs towards COVID-19 preventive practices could influence the acceptance of the vaccine by their local populations.10 11
Katsina State (as of 23 February 2023) recorded 2418 COVID-19-positive cases and 37 COVID-19-associated deaths.1 The state received 107 504 doses of the Oxford/AstraZeneca COVID-19 vaccine to vaccinate priority individuals, including HCWs.12 This is one of the earliest studies to evaluate acceptance of the COVID-19 vaccine among HCWs in Northern Nigeria. We assessed the acceptance of the COVID-19 vaccine and its associated factors among HCWs in Katsina State, Nigeria.
Methods
Study area
This study was conducted in Katsina State, Northwestern Nigeria. The state has 34 local government areas and a population of 5 801 584.13 The state is dominated by the Hausa and Fulani ethnic tribes.13
Survey methodology
The survey questionnaire (online supplemental file 1) was designed to assess acceptance of the COVID-19 vaccine by HCWs. The questionnaire had two sections: section A evaluated the demographics of HCWs and section B evaluated the acceptance of the vaccine by HCWs. Two independent academic reviewers pretested and validated the survey for its content, face validity and ease of administration. The questionnaire was administered electronically (via Google Forms) as part of the COVID-19 operational research at the Katsina State Emergency Operations Centre between 1 May and 22 May 2021. We made the online survey short and simple to obtain the fastest response from extremely busy HCWs when the pandemic still ravaged the community. Participants were recruited using non-probability sampling (snowballing). Through the state medical association, we shared a link to the questionnaire via email and social media platforms (such as WhatsApp and Twitter) to capture all health facilities registered in the District Health Information Software 2. We did not allocate the survey to public and private health facilities.
Supplemental material
The inclusion criterion was that the participant had to be a HCW or a HCW in training to provide care in Katsina. Using 95.6% as the proportion of acceptance (as reported for Northwest Nigeria),14 99.99% confidence level, 5% margin of error, and 10% non-response rate, a sample size of 281 respondents was calculated for this study.
Statistical analysis
The data generated from this study were analysed using the Statistical Package for Social Sciences V.26. Descriptive statistics are presented as frequencies and proportions. We conducted a univariate logistic regression analysis to evaluate the effect of the independent variables (sociodemographic variables) on a binary outcome variable (acceptance of the COVID-19 vaccine). All the significant variables at p≤0.05 were retained and included in the final model of the multivariable logistic regression analysis using the logit function and α at 0.25.
Patient and public involvement
The participants were not involved in the planning or execution of the study.
Results
A total of 793 HCWs were included in this study. Of these, 65.4% (n=519) were male, 36.2% (n=287) were aged 30−39 years, 27.1% (n=215) were community health workers, and 87.5% (n=694) were from public health facilities, as shown in table 1. The majority, that is, 96.3% (n=764) of HCWs, complied with and practised COVID-19 preventive measures such as regular handwashing (with soap and water or using hand sanitisers). However, only 75.1% (n=601) of the HCWs frequently used facemasks, 78.6% (n=623) maintained social distancing, and 80.8% (n=641) avoided crowded places, as shown in table 2.
Sociodemographic characteristics of participants
Vaccine acceptance among healthcare workers in Katsina State (n=793)
Of the HCWs, 80.4% (n=638) were tested for COVID-19 using PCR or rapid diagnostic test kits (RDT kits). Of the HCWs screened for COVID-19, 10.8% (n=65) tested positive and were managed appropriately. The majority of the HCWs, 97.3% (n=765) believed that the Oxford/AstraZeneca COVID-19 vaccine received by Nigeria was safe, and 74.7% (n=573) were of the opinion that the vaccine should be mandated for all Nigerians. Of all HCWs who participated in this survey, 90% (n=714) had received the first dose of the Oxford/AstraZeneca COVID-19 vaccine. Only 4% (n=32) of the respondents were unsatisfied with the government’s handling of the pandemic, as shown in table 2.
HCWs aged 30–39 years were more likely (aOR: 7.06; 95% CI 2.36 to 21.07; p<0.001) to accept the vaccine than others. Also, HCWs that had been tested for COVID-19 were more likely (aOR: 7.64; 95% CI 3.62 to 16.16; p<0.001) to accept the vaccine than those that had not, as shown in table 3.
Factors affecting the acceptance of the Oxford/AstraZeneca COVID-19 vaccine among healthcare workers
Discussion
Vaccination is a crucial public health intervention that is used to prevent and control infectious diseases.15–17 The arrival of the Oxford/AstraZeneca COVID-19 vaccine in Nigeria marked the beginning of another phase in controlling the pandemic and renewed hope in the fight against the disease.
Our findings showed that most (90%) of the HCWs in Katsina State had received at least the first dose of the Oxford/AstraZeneca COVID-19 vaccine. This was lower than that reported by another study from Nigeria, which showed a 95.6% acceptance of the COVID-19 vaccine in Northwest Nigeria.14 But a study from Greece reported lower vaccine uptake rates of 77% and 51% among physicians and nursing staff, respectively.11 About 97% of the HCWs in our study believed the vaccine to be safe and effective. A systematic review and meta-analysis18 that assessed the vaccine acceptance in Africa showed that the acceptance rate for the vaccine’s safety and effectiveness was high in HCWs, which could explain the high vaccine uptake results in our study. Most (80%) HCWs had COVID-19 testing done before participating in our study. There is no clear explanation for why the acceptance rate among HCWs is particularly high in Northwestern Nigeria. However, vaccine acceptance by HCWs are important for increasing acceptance by community members because HCWs serve as a trusted source of public health information, and their advice could be a determining factor for decision-making in the community.3 Further, the majority (84.5%) of the HCWs in our study rated the government’s handling of the pandemic highly (rated as ‘Good’ or ‘Excellent’), and only 4% were not satisfied with it (rated as ‘Fair’ or ‘Poor’). A high acknowledgement of the situation and government response along with a positive perception of the COVID-19 vaccine could have influenced and led to increased acceptance rates.19
Most of the HCWs complied with and practised COVID-19 preventive measures. Moreover, HCWs were more compliant with regular hand washing using soap and water or hand sanitisers compared with the other COVID-19 preventative practices. Our findings showed that HCWs aged 30–39 years and a history of prior COVID-19 testing strongly influenced COVID-19 vaccine acceptance.
Our study showed that only about 75% of the HCWs frequently used face masks, maintained social distancing and avoided crowded places as the pandemic progressed. It is likely that 25% of the HCWs in our study did not observe non-pharmacological preventive practices due to pandemic fatigue.19 This pandemic fatigue could have been compounded by the availability of vaccines, among other factors.19 However, HCWs should follow and adhere to COVID-19 preventative practices despite the availability of COVID-19 vaccines. Moore et al20 and Yu et al21 reported that non-pharmacological interventions are still required to control the pandemic despite the global COVID-19 vaccine rollout.
Our findings showed that the self-reported prevalence of COVID-19 among HCWs in Katsina was 10.8%. Alasia and Maduka22 reported higher (15.3%) COVID-19 prevalence rates, whereas Ogboghodo et al23 reported lower (5.3%) prevalence rates among HCWs in the Rivers and Edo states of Nigeria, respectively. It remains to be ascertained whether the HCWs in our study contracted SARS-CoV-2 via community transmission or contact with infected patients.
Our findings showed that the main factors influencing increased acceptance of the COVID-19 vaccine among HCWs in Katsina were age and prior COVID-19 testing. HCWs aged 30–39 years were more likely to accept the vaccine than other HCWs. This may be due to the higher percentage of this age group in the health sector workforce in Nigeria. Shekhar et al24 observed a similar trend and reported that the COVID-19 vaccine acceptance increased with age.
Increased acceptance of the COVID-19 vaccine can be predicted by the previous testing status of HCW. Eighty per cent of the participants were tested using PCR or RDT kits. There was a mandatory PCR testing policy in Katsina for all HCWs at the peak of the pandemic. However, this was not the case after vaccination was rolled out. To save resources, RDT testing was introduced only for HCWs suspected of having contracted COVID-19. The willingness to be tested reflected the level of education and knowledge of HCWs, which were additional factors that could influence vaccine acceptance by HCWs.11 24 25 These results align with the findings of Maltezou et al11 and Shekhar et al.24
Although not statistically significant, vaccine acceptance was lower in private than in public health facilities. This may be due to the increased risk perceptions of COVID-19 among HCWs in public health facilities compared with private health facilities. Risk perception also affects vaccine uptake.3 Another factor that may explain the disparity in vaccine uptake among HCWs in public and private health facilities is the prioritisation of vaccine availability to the frontline HCWs of the public health facilities who managed most of the COVID-19 cases. However, it is imperative to increase vaccine uptake among HCWs in private health facilities by including them among those prioritised for vaccination and making private health facilities a site of vaccination for the public. This would, in general, increase the uptake of vaccine among HCWs, prevent infection and reduce the loss of the essential workforce to infection and death.24 As identified by Shekhar et al,24 this strong association between HCW intend to be vaccinated and recommend the vaccine to others will positively impact vaccine uptake among the public.
Similar to the findings of a Congo study,3 in this study, the male gender was more predisposed to accepting the vaccine (though not statistically significant). The possible reason for this could be a high ‘risk perception of COVID-19’ in males compared with females.3 Similar to the findings of this study, a Ghanian study reported that females were more likely to reject the COVID-19 vaccine.10 As explained by a study conducted in the USA, females were more concerned about the safety of the COVID-19 vaccine than males26 which could possibly be why females did not readily accept the vaccine.
The main strengths of our study are a large sample size and timeliness of the survey. The main limitation is the small number of physicians who participated in the survey. Physicians have the greatest impact on the decision-making by the population. In addition, our survey did not capture the reasons for acceptance or rejection of the COVID-19 vaccine. Since we did not use a probability sampling method, our study might have sampling bias because some health facilities and HCWs could not access the online survey. Thus, the generalisability of the survey cannot be guaranteed. As this was a web-based survey, we could not extract information from non-respondents. The bias was reduced by increasing the sample size, using a defined target population, and making the survey as short as possible.
Conclusion
This study reported a high acceptance of the COVID-19 vaccine among HCWs in Katsina State, Northwest Nigeria. The main predictors of increased vaccine acceptance were age and prior testing for COVID-19. Our recommendations to hospitals and the government has contributed to the successful vaccination of HCWs and the community. We recommend that hospitals invest in educating and vaccinating HCWs and encourage HCWs to educate their patients on the importance getting vaccinated. Governing bodies can use the findings of our research to guide vaccination, practice, research and policies on COVID-19 and other pandemics. Future research should evaluate other factors, such as the uptake of the second and booster doses and the reasons for accepting or not accepting the vaccines.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
The ethical approval of this study was obtained from the Katsina State Ministry of Health (Reference number: MOH/KS/EHC/77/98). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We thank Dr. Muftau Oyewo for reviewing this manuscript. We would like to thank Editage (www.editage.com) for English language editing.
This post was originally published on https://bmjopen.bmj.com