COVID-19 Vaccine Survey among Healthcare Workers. A Community Experience.

INTRODUCTION In December 2019, the coronavirus (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) made its first appearance in Wuhan, China with a pandemic declared by March 2020. As the death toll continued to rise, the Centers for Diseases Control and Prevention (CDC) recommended healthcare workers to strongly encourage the general population to receive COVID-19 vaccinations. For this to be effective, it is important to understand the general perceptions of the health care workers and persons associated with the healthcare industry towards their acceptance of the vaccine. METHODS The authors of this 2021 cross-sectional study administered a 28-item survey to a convenience sample of 1,257 (43.1%) healthcare system workers out of a total of 2,915. The survey assessed respondents’ demographic information, COVID-19 vaccine status, work-related exposures to COVID-19, reasons for receiving or refusing the vaccine, and primary sources of vaccine related information. Respondents were classified as vaccine status/intention positive or negative. RESULTS Those in the youngest 18 - 35 years age group were significantly less likely to receive the vaccine (p < 0.01) and male healthcare workers were significantly more likely to receive the vaccine (p = 0.01). White respondents, 759 (77.9%) were also more likely to receive the vaccine than African-American, 127 (13%). It was more likely for persons to be vaccinated when encouraged/provided (p = 0.01) information by their respective employers. A subgroup of 277 (22.0%) respondents reported their employer as the primary source of vaccine information, causing the authors to conclude that employer information was the most influential informational factor impacting COVID-19 vaccination. CONCLUSION Vaccine hesitancy continues to be a major obstacle hampering the success of COVID-19 vaccination promotion programs. Results indicate that a combination of a prior COVID-19 diagnosis, information dispensed by a person’s employer, persons’ home living situations, and contact with persons who had an uneventful post vaccination experience increased the likelihood of vaccination.


INTRODUCTION
In December 2019, the coronavirus (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) made its first appearance in Wuhan, China with a pandemic declared by March 2020. As the death toll continued to rise, the Centers for Diseases Control and Prevention (CDC) recommended healthcare workers to strongly encourage the general population to receive COVID-19 vaccinations. For this to be effective, it is important to understand the general perceptions of the health care workers and persons associated with the healthcare industry towards their acceptance of the vaccine.

METHODS
The authors of this 2021 cross-sectional study administered a 28-item survey to a convenience sample of 1,257 (43.1%) healthcare system workers out of a total of 2,915. The survey assessed respondents' demographic information, COVID-19 vaccine status, work-related exposures to COVID-19, reasons for receiving or refusing the vaccine, and primary sources of vaccine related information. Respondents were classified as vaccine status/intention positive or negative.

RESULTS
Those in the youngest 18 -35 years age group were significantly less likely to receive the vaccine (p < 0.01) and male healthcare workers were significantly more likely to receive the vaccine (p = 0.01). White respondents, 759 (77.9%) were also more likely to receive the vaccine than African-American, 127 (13%). It was more likely for persons to be vaccinated when encouraged/provided (p = 0.01) information by their respective employers. A subgroup of 277 (22.0%) respondents reported their employer as the primary source of vaccine information, causing the authors to conclude that employer information was the most influential informational factor impacting COVID-19 vaccination.

INTRODUCTION
The coronavirus 2019 (COVID-19) pandemic is an ongoing pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The virus first appeared in Wuhan, China in December 2019 and was declared to be a pandemic by March 2020. By June 2021, the world had recorded over 176 million cases, with over 3.8 million deaths primarily attributable to COVID- 19. 1 As mortality and morbidity rates have increased worldwide, researchers have worked to better understand the pathology of the virus. Unfortunately, evolving preventive and treatment measures have not reached a definitive conclusion, resulting in global social and economic disruptions. [2][3][4][5] In addition to the development of effective hospital treatment regimens, proven vaccines have now been formulated to prevent severe COVID-19 illness from occurring. 6,7 As COVID-19 pandemic rates have increased, as of publication of this article, there have been over 461 million cumulative cases and over 6 million worldwide deaths. 6 Although various clinical trials have shown vaccines to be highly effective, skepticism and negative public opinions and hesitancy towards COVID-19 vaccination continues to be an ongoing hurdle. [7][8][9] Vaccine Hesitancy appears to be one of the major overall obstacles hampering the success of most vaccination programs. [7][8][9][10] Studies have also demonstrated only a 60-67% acceptance of COVID-19 vaccination among US healthcare workers due to lack of trust in the vaccine, insufficient information, and other personal beliefs. 10,11 In 2020, the CDC officially encouraged all healthcare workers and the general population to receive an available COVID-19 vaccination. 12 However, examining the varied perceptions of the healthcare workers towards COVID-19 vaccines remains a vital component of public health vaccination programs. 13

STUDY OBJECTIVE
The objective of this 2021 cross-sectional survey study was to investigate the primary factors influencing COVID-19 vaccine acceptance and hesitancy in a convenience sample of mid-Michigan healthcare workers.

STUDY DESIGN
The authors utilized a quantitative cross-sectional study design. After IRB approval in February 2021, a survey invitation via email was sent to all healthcare worker employees at a hospital medical center in Flint, Michigan. Healthcare workers were defined as all healthcare personnel employed by the healthcare system who were directly or indirectly involved in patient care. A total of 1,258 (43.1%) responses were collected from a solicited 2,915 documented healthcare workers over a period of 21 days.
The survey that was developed by the authors consisted of 28 multiple choice and open-ended questions (Appendix I). Survey items asked respondents to report their sociodemographic characteristics (e.g., Age, Gender affiliation, Racial/Ethnicity Affiliation, etc.) and personal clinical information (i.e., possible pregnancy, medical comorbidities, COVID-19 vaccine status, work-related exposure to COVID-19, reasons for getting or not the vaccine, knowledge about the vaccine, and sources of information influencing vaccination decisions). Quantitative survey item data results were analyzed by second author CRB.

SELECTED STUDY OUTCOME
The vaccination status of each healthcare worker respondent was determined from their responses to a series of multiple-choice questions regarding their current vaccination status or intention to get vaccinated. The question "Will you take the vaccine?" was paired with the following response options for those answering "Yes": "I have already taken the vaccine", "No", and "Not sure". Those answering the first two options (i.e., "Yes" and "I have already taken the vaccine" at least three months ago) were classified as "vaccine status/intention positive" while those answering the other two options were classified as "vaccine status/intention negative." STATISTICAL ANALYSES Before conducting any inferential statistical analysis, the authors assessed data distribution outliers (i.e., out of range values), and completed data cleaning to review frequencies, proportions, descriptive statistics and figures (e.g., histograms and box and whisker plots).
Bivariate correlation analytic procedures were conducted to determine any associations between the study explanatory variables (i.e., (categorized) Age Group, Gender Affiliation, Racial/Ethnicity Affiliation, COVID-19 exposure level, primary source of COVID-19 information, intention to get vaccinated, etc.) and self-reported COVID-19 vaccination status/intention. Such analyses included Chi Square and Fisher exact tests.
Multivariate logistic regression analytic procedures were also conducted to examine any relationship between study explanatory variables (i.e., Age Group, Gender Affiliation, COVID-19 exposure level, primary source of COVID-19 information, intention to get vaccinated, etc.) and the main selected study outcome (i.e., COVID-19 vaccination status/ intention). All analyses were conducted by author CRB using the Stata statistical software package (Stata Corporation, College Station, TX). The usual 0.05 Type I error threshold for statistical significance was observed when interpreting results.

RESULTS
A total of 1,257 (43.1%) healthcare workers replied to the survey out of 2,915 questionnaire invitations. Of those who replied, 965 (76.8%) respondents had already received their first COVID-19 vaccine dose. As shown in Table 1, bivariate analyses showed that categorized Age Group was significantly associated with vaccine status (p < 0.01). Male healthcare workers were also significantly more likely to receive the vaccine than females (p = 0.01). White respondents were also more likely to receive the vaccine than African -Americans (p = 0.01). Table 1 demonstrates several other factors (e.g., prior COVID-19 diagnosis, living with children, etc.) that significantly influenced each respondent's vaccination status. However, possessing multiple medical comorbidities (e.g., Hypertension, Diabetes, Thyroid disorders, Cardiac or Pulmonary comorbidities, etc.) was not a significant factor influencing vaccination status.   Healthcare workers with less than a graduate degree were significantly less likely to have received the COVID-19 vaccine at the time of the survey. Other factors significantly related with vaccination status were a previous COVID-19 diagnosis (p < 0.01) and perceived level of concern about COVID-19. Compared to no concern, an upward trend was observed by level of concern; low level (p < 0.01), medium level (p < 0.01), and high level (p < 0.01). (Table 2) DISCUSSION Due to their increased relative COVID-19 risks, healthcare workers were generally the first recipients of the COVID-19 vaccination program. 14,15 Similar to our study results, Race/ethnicity affiliation has been found to be a significant factor influencing the phenomenon of vaccine hesitancy,   with 83.0% of African-Americans across the U.S. being less receptive to receiving the vaccine. 11 We found from our survey results that the reported frequency and risk of exposure to the COVID-19 virus had no impact on healthcare workers' likelihood of getting vaccinated. However, respondents' household composition sometimes served as a statistically significant influencing role. (Table 2) Our survey results are consistent with findings noted in other studies where respondents were more likely to be vaccinated if they were in contact with a person who had received the vaccination and had not suffered significant side effects. 16 As shown in Table 1, 272 (22.0%) of respondents indicated their employer as their primary source of vaccine information. Unfortunately, we were unable to precisely define "Other" sources from the way the survey had been developed. Based on the available data from the survey, the conclusion is that employers in the community may prove to be a key source of vaccine guidance to either promote or discourage vaccination. In addition, the Supreme Court passing a limited mandate on health care workers requiring vaccination as of January 2022 may help accelerate vacci-nation in persons who originally planned to delay or were contemplating vaccination due to increased economic risks from unemployment. 17 Vaccine Hesitancy appears to be one of the major obstacles hampering the success of most vaccination programs. [7][8][9][10][11] Vaccine hesitancy is considered to be a delay in acceptance or refusal of vaccination despite availability of vaccination services. Vaccination acceptance is considered a complex decision-making process that involves three factors, which include complacence, confidence, and convenience. 18 As per the article published, confidence is defined as trust in (i) the effectiveness and safety of vaccines; (ii) the system that delivers them, including the reliability and competence of the health services and health professionals and (iii) the motivations of policymakers who decide on the needed vaccines. 18 A 2007 meta-analysis conducted regarding a person's behavior towards the concept of vaccination shows that people perceive the risk of vaccination in two dimensions. 19 The first one being the perceived likelihood of harm if no action is taken compared to the perceived consequences of side effects from the vaccination itself. 19.
COVID-19 Vaccine Survey among Healthcare Workers. A Community Experience.

Spartan Medical Research Journal
In more recent studies it has been demonstrated that decision making, and perceived risks are often influenced by health care professionals, government, and/or public health institutions. 20,21 Individual's decisions and hesitancy towards various vaccinations have been intricately linked to social, emotional, political, and cultural beliefs. 22 Our results suggest that the strategic provision of information from workers' employers and health officials may serve to increase the likelihood of healthcare workers and others to get vaccinated.

STUDY LIMITATIONS
Our three-week cross-sectional survey study was conducted with a local convenience sample of healthcare workers to examine current factors influencing vaccine hesitancy levels. Worker opinions may have changed as more people received the vaccine without incident. Our survey could not identify all specific reasons influencing respondents' vaccine opinions as most simply choose an option of "Other" response without offering further detailed comments.

CONCLUSION
These results indicate that vaccine hesitancy remains one of the major obstacles to our nation's implementation of COVID-19 vaccination programs. The information obtained from a person's employer, their personal characteristics, and contact with persons who have had an uneventful post COVID-19 vaccination course may in many cases serve to increase healthcare workers' likelihood of getting vaccinated. CONFLICT