Knowledge, Attitude, and Practice among Dubai Health Authority Health Care Workers toward the COVID-19 Vaccine

Introduction: Vaccine attitude can change disease progress, facilitate herald immunity among the community, and stop disease progression. According to the available data, there is no current curative treatment against the virus. The only way to stop the spread of infection is to develop the vaccine and accelerate the vaccine, as shown previously with the influenza pandemic. Objective: The study’s main goal was to investigate health care workers’ knowledge, attitude, and practice toward the coronavirus disease 2019 (COVID-19) vaccine in Dubai Health Authdority (DHA), United Arab Emirates (UAE). Methods: In April 2021, an anonymous cross-sectional comparative study measured the willingness and hesitancy to take the COVID-19 vaccine among health care providers in the primary health care sector at DHA. Results: In terms of COVID-19 vaccine knowledge, there was widespread agreement on the significance of the vaccine in preventing the transmission of illness (91.6%) and on the vaccine’s value for the public and community (95.6%). Furthermore, based on health care providers’ opinions, most individuals agreed to promote the COVID-19 vaccination in patients, family, and friends (92.7%), with just 6.9% doubtful. In actuality, 72.1 percent of those who got the vaccination received two doses, while 27.9% received just one dosage. In terms of vaccine type, Pfizer (72.7%), Sinopharm (23.8%), and AstraZeneca (3.6%) were the available vaccines during the study period. Discussion: The majority of participants agreed that the vaccine is essential for health care providers and the community (more than 90%), and they were willing to recommend it to their families (92.7%). They also agreed that the vaccine is necessary to prevent the spread of the disease (91 percent), boosting vaccine confidence. Conclusion: COVID-19 vaccine was widely accepted by Dubai’s health care workers. Several factors were identified as significant determinants of vaccine acceptance. UAE health care authorities can use the study’s findings to develop public health policies and implement campaigns to address concerns about the COVID-19 vaccine and other emerging infectious diseases.


Introduction
The coronavirus disease 2019 (COVID-19) pandemic causes a burden on the health care system among all the karger@karger.com www.karger.com/dmj countries worldwide. The virus was linked to the seafood and wet animal wholesale market in Wuhan, Hubei Province, China, in late December 2019 [1,2]. In late December, the World Health Organization (WHO) declared a respiratory disease outbreak caused by a new coronavirus severe acute respiratory syndrome coronavirus-2 in China in 2019. Nevertheless, based on the last data published by the WHO in March 2020, the new virus has been disseminated in almost 70 countries, and the epidemiologic picture is changing daily [3]. The disease caused by severe acute respiratory syndrome coronavirus-2 affects the respiratory tract and ranges from mild symptoms like cough, loose smell, headache, and body ache to severe illness, which can lead to death with different complications; this disease is known as COVID-19 [2]. The COVID-19 impacted public health and the economy globally. The available data show no current curative treatment against the virus [4][5][6]. The only way to stop the spread of infection is to develop the vaccine and accelerate developing the vaccine, as shown previously with the influenza pandemic. On June 22, 2021, the WHO announced 287 COVID-19 vaccine candidates in the clinical evaluation; 18 are in phase 3 trials [4,7]. In United Arab Emirates (UAE), a COVID-19 clinical trial was conducted as a phase 3 trial. The clinical trial results conducted about the Sinopharm vaccine show a high rate of disease prevention and offer an excellent immune response to the vaccine and developing antibodies.
Moreover, it shows a high percentage rate of prevention for moderate to severe illness of COVID-19. In addition to the disease protection, the high safety profile with the Sinopharm vaccine and no concern related to the safety issues [8]. Although there was good progress in developing vaccination with a different mechanism and impressive results are available, the big challenge was accepting the vaccine among the community, especially health care providers, considering the high risk of getting infected during the pandemic. Vaccine attitude can change disease progress, facilitate herald immunity among the community, and stop disease progress [9,10]. According to the WHO, vaccine hesitancy means the delay in accepting or refusing vaccinations despite their availability [8]. Many people believe that vaccines are unsafe due to social media reports concerning vaccine scares and controversies; this contributes to population declines in vaccination rates and outbreaks of vaccinepreventable diseases. A few systematic reviews had shown that vaccine acceptance rates among health care workers (HCWs) ranged between 27.7 and 78.1% when COVID-19 vaccines were introduced, the main concerns being safety and side effects [11,12].
Several studies noted that age, sex, and occupation were positive predictors of hesitance, but others found that vaccination history and self-perceived risk were facilitators of vaccine acceptance [13][14][15]. The existing literature cites hesitancy in higher income countries primarily due to concerns about the safety of the COVID-19 vaccine, including the rapid phase of vaccine development [16][17][18]. Studies about the health care provider willing to take the vaccine show different responses with an average rate of health care providers eager to take it [19,20]. Research conducted in the USA indicates around 56% of health care providers were not sure if they would take the vaccine or not. Only 36% were willing to take it, and a minimal percentage, around 8%, does not plan to take the COVID-19 vaccine when it is available [19]. Therefore, the study's main objective was to investigate HCWs' knowledge, attitude, and practice toward the COVID-19 vaccine in Dubai Health Authority (DHA), UAE.

Study Design, Population, and Sampling
The study was conducted in Dubai among primary HCWs at the DHA, which oversees the health system of Dubai, UAE. There were twelve primary health care centers included in the study at the time of the study. HCWs must register with the central Shryan licensing system to practice medicine within the Emirate. Statistical information obtained from the DHA website indicates that the total number of HSWs at DHA in 2019 is 9,602 and the total number of health care providers at primary health care centers is 1,606 [21]. A representative sample was calculated using the online sample calculator, taking a margin of error of 5%, and the confidence interval of 95% sample size is 365 [22]. Ethical approval (DSREC-01/2021-17) was obtained from the DHA research and Ethical Committee and from the primary health care centers. DHA HCWs working in primary health care centers were invited to participate in an electronic questionnaire (created by Google Forms) between January 2021 and April 2021 using a single response feature. The study included physicians, nurses, and allied health workers working at primary health care centers, who could read English and had access to the internet via computer and/or smartphone. The link will be directed to the questioner's page once an online consent has been obtained. A total of 562 responses were received from participants.

Measures
A self-administered questionnaire (online suppl. Appendix I; for all online suppl. material, see www.karger.com/doi/10.1159/000530217) was designed based on prior studies about the COVID-19 acceptance and other infections like H1N1 influenza A virus subtype (H1N1) vaccine acceptance and hesitancy among care providers [21,22]. The context of the questionnaires included (1) sociodemographic data: age, sex, designation, years of experience, marital status, having children, and history of chronic disease; (2) information about the COVID-19 vaccine, willingness to take the vaccine, and belief regarding vaccine recommendation to the community; and (3)  concerns the personnel's experience with the COVID-19 vaccine and previous infection with COVID-19. All the questions were closed ended with "yes and no" or tick box answers. The survey link was formulated in a way that was not submitted or closed until all the questions were answered to ensure the availability of all data collected.

Statistical Analysis
The survey's outcome is to measure the health care provider's knowledge about COVID-19 and whether they are willing to take the vaccine or advocate for it among the community. Additionally, descriptive statistics, including number, percentage, and p value were used to define the sociodemographic characteristics, risk factors, knowledge about the vaccine, and factors that affect their acceptance and attitude toward having the COVID-19 vaccine. It was observed that there were two study groups, the vaccine acceptance group, which received the vaccine, and the vaccine delay group, which did not receive the vaccine as per participant's response due to recent COVID-19 infections, and protocol during that period was to wait 3 months and the contraindication list for vaccines was continually updated. As a result, we have referred to these individuals as vaccine delay groups. The baseline characteristics were compared between health care respondents in the two groups (vaccine acceptance group vs. vaccine delayed group), with the χ 2 test to analyze the significance of the association between categorical variables. Logistic regression at univariate and multivariate level was then performed between the vaccine acceptance and vaccine delay groups to identify the influencing factors of vaccination acceptance and the odds ratios along with 95% confidence interval were reported. All data were analyzed using SPSS. All data were analyzed using "IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp." for data analysis.

Knowledge
Detailed results of knowledge about COVID-19 vaccine show high agreement about the importance of vaccine to reduce the spread of infection (n = 515, 91.6%) and n = 537 (95.6%) agreed about the vaccine for the public and community. Participants agreed that they were at high risk of exposure to COVID-19 (n = 509, 90.6%), and only n = 29 (5%) disagreed. Participants who knew the importance of the vaccine for health care providers were n = 536 (95.4%). Knowledge about vaccines shows that only n = 275 (48.9%) are aware of the vaccine and n = 204 (36.3%) were concerned that they do not know enough about it.

Attitude
Most participants agreed to recommend the COVID-19 vaccine for patients, family, and friends (n = 521, 92.7%), and only n = 39 (6.9%) were unsure about it. Regarding trusting information about the immunization received from public health, n = 476, (84.7%) show trust, n = 21 (3.7%) were not trusting the data, and n = 65 (11.6%) were not sure. Mandating the vaccine among health care providers, n = 423 (75.3%) agreed on it, and n = 75 (11.4%) were against making the COVID-19 vaccine mandatory among health care providers. Furthermore, regarding mandating vaccines among the general public, n = 400 (71.2%) agreed it should be mandatory, and n = 98 (17.4%) were against that.

Practice
Among participants, n = 130 (23%) had COVID-19 infection; regarding willingness to take the vaccine, n = 362 (64.4%) were willing to take the vaccine and n = 200 (35.6%) were not willing to take the vaccine. Those who were not willing to take the vaccine (n = 20, 10%) were against the vaccine in general; some reported lacking time to take the vaccine (n = 26, 13%) and n = 28 (14%) did not get an appointment for the vaccine, some of them reported previous COVID-19 infection (n = 48, 24%), and some of them reported that they are falling under the category of contraindication to having the vaccine (n = 78, 39%) ( Fig. 1).
Influencing Factors in Accepting COVID-19 Vaccine Factors affecting health workers to receive the vaccine: the higher the age, the more likely the health worker is to receive the vaccine, especially for those aged 45 years and above (χ 2 = 15.748a and a two-tailed p value = 0.003) (Fig. 2). Another factor affecting vaccine acceptance is job nature range from most likely to less likely: physicians, radiology, nurses, dental technicians, and more minors among pharmacists (χ 2 = 17.721a and a two-tailed p value = 0.007) (Fig. 3).
Years of experience play an essential role in accepting the vaccine; the more years of experience, the more likely the health worker will receive the vaccine (χ 2 = 10.846a and a two-tailed p value = 0.028) (Fig. 4). Finally, a HCW with chronic disease is more likely to receive the vaccine than others with no chronic disease history (χ 2 = 4.275a and a two-tailed p value = 0.039) (Fig. 5).
Logistic Regression Analysis -Predictors of Intention to Get Vaccinated against COVID-19 Logistic regression was performed to ascertain the effects of age, years of experience, job category, and presence of chronic disease on the likelihood that participants will receive the COVID-19 vaccine ( Table 2). At univariate logistic regression, in comparison to individuals under 25 years of age, the odds for age groups 45-54 and 55-56 years were found to be greater than one which implies increased likelihood of accepting vaccinations. However, the association with age was not significant at both univariate and multivariate levels. Similarly, with regard to working experience, individual with experience more than twenty years was only found significantly associated with accepting vaccination at univariate level and become insignificant in an adjusted model. In terms of occupation, nurse's pharmacist and others were found to be inversely associated with acceptance of vaccine at 5% level of significant in both univariate and multivariate models compared with physician (reference category). The likelihood of accepting vaccination was 54% higher in individuals with chronic comorbid conditions and was statistically significant at univariate level.

Discussion
An increased vaccination rate for COVID-19 may result in faster epidemic termination, the return of normal activities, and a reduction in preventative measures. As transmission, morbidity, and mortality rates have declined, research suggests that vaccination may effectively reduce and contain the COVID-19 pandemic's mortality and morbidity [23]. However, there is a lack of knowledge regarding the obstacles to COVID-19 vaccine acceptance, especially among HCWs. The WHO has identified vaccine hesitancy as one of the top 10 threats to global health [24].
To date, most studies have focused on vaccination intentions rather than vaccination uptake, and most have not examined COVID-19 vaccine acceptance among health workers. A cross-sectional study was  conducted in April 2021, and vaccination uptake may vary over time due to changes in vaccine guidelines, local infection rates, or government regulations. The study investigated to find health care providers' knowledge, attitude, and practice about the COVID-19 vaccine during a pandemic. It shows they are concerned about limited vaccine safety data, especially since it has been authorized as emergency use did not pass the final  stage of approval. There were 36.3% who were concerned that they did not have enough knowledge about the vaccine, 46.1% were concerned about short-term side effects, and 52.5% were worried about long-term side effects. Moreover, they were concerned that the vaccine was approved through an accelerated process (50%). A study conducted to look at the willingness and intention of HCWs to receive vaccines in Abu Dhabi (the capital of the UAE) revealed 10.8% were hesitant to receive vaccines. The reasons for vaccine hesitancy were fear of potential side effects (48.5%), lack of reliable data regarding vaccines (37%), lack of trust due to rapid vaccine development (11%), and only 3.4% "do not believe in vaccine in general," similar to our study where only 3.6% do not believe in vaccines [25]. Based on a meta-analysis conducted in Africa, vaccine hesitancy was primarily due to concerns regarding vaccine side effects, efficacy, insufficient vaccine information, and lack of trust in vaccine manufacturers and the source of vaccines [26]. As a result of the common concerns among health care providers, improving vaccine confidence might promote vaccination [14].
Health care providers trust the public health information regarding vaccines, which was about 84.7%. This can reflect on their recommendation to have vaccines among the community and health care providers and the importance of vaccines during the pandemic. The attitude section shows agreement on mandating the vaccine among health care providers (75.3%) and 71.2% HCWs agreed that vaccines should be mandatory for the community.
In the practice section, the majority of health care providers took the vaccine (64.4%). Study was conducted at the beginning of the vaccine campaign, which reflects a high percentage of the vaccine coverage and 23.1% reported a previous infection, which can be one reason not to vaccinate. Suppose we modify the rate who received and those who were unable to receive the vaccine because they are contraindicated or had a previous infection. In that case, the modified vaccine coverage will be 86.8%.
According to the WHO, vaccine hesitance is a reluctance or refusal to receive a vaccine despite the availability of the vaccine [24]. As part of its vaccination program, the UAE government has identified the following groups as prioritized to vaccination: senior citizens and residents (those over 60 years of age), people of determination, people with chronic illnesses, and people employed in the health and education sectors [27]. According to our study, approximately 13.2% of individuals are hesitant to receive the COVID-19 vaccine for various reasons. Nearly 9.6% of participants reported scheduling and appointment difficulties, although they were prioritized in getting the appointment and receiving vaccinations, and only 3.6% reported refusing to receive vaccinations.
A study conducted in Turkey found that half of the employees of family health centers agreed to receive vaccinations, one-fifth (approximately 20%) refused to receive vaccinations, and over 30% were unsure whether to obtain vaccinations [28]. Other studies of vaccination intention among health care professionals have found that vaccination acceptance varies between 30 and 80 percent [15,16,23]. According to another study conducted in Singapore, the primary health care clusters saw a 90% vaccination rate comparable to 95% as uncovered in their study. Nevertheless, 52.9% of HCWs did not complete the survey; therefore, the true hesitancy rate is more likely to be higher than 5.1% since nonrespondents are more likely to be hesitant, according to study authors [29]. As compared to the listed studies, the HCWs working in primary health care at DHA have a very low level of hesitancy.
However, we did not examine secondary and tertiary HCWs who work directly with COVID-19 or their acceptance and hesitancy toward the vaccine.
Studies conducted among HCWs have found direct patient contact and higher perceived risk as factors associated with greater vaccine acceptance [15]. Accordingly, we can conclude that increasing community vaccination rates for COVID-19 may coincide with increasing disease prevalence. Further studies in this field looking at the possibility of a longitudinal relationship could shed light on the strength of this possible correlation. This in turn can enhance the effectiveness of disease prevention through widespread COVID-19 vaccination. A Chinese study also recognized that the request for vaccination by employers might improve vaccine acceptance [30]. Study results from Turkey showed age, gender, profession, and history of seasonal influenza vaccination were related to vaccine acceptance [28]. The following factors were identified in our study as associated with vaccine acceptance: age; the higher the age, the greater the probability that the health worker will receive the vaccine. Job nature ranges from most likely to least likely: physicians, radiologists, nurses, dental technicians, and more minors among pharmacists. Another factor was years of experience; the more years of experience, the greater the probability that the health worker will accept the vaccine. In addition, HCWs with chronic diseases are more likely to receive the vaccine than those without such a history. In September 2020, the UAE government will authorize the use of COVID-19 vaccine in an emergency situation; to date, there are four vaccines against COVID-19 infection in the UAE. The four companies are Sinopharm, Pfizer-BioNTech, Sputnik V, and Oxford-AstraZeneca [27]. UAE residents and citizens can obtain this vaccine free of charge. Reports state that among the four vaccines currently available in the UAE, Sinopharm is the most trusted vaccine (50%), Pfizer-BioNTech with 27%, and the Russian vaccine Sputnik V with 6% [31]. The most popular vaccines among HCWs in Dubai were Pfizer (72.7% of those who received a vaccination received it), Sinopharm (23.8%), and AstraZeneca (3.6%). However, the Sputnik vaccine was unavailable from the DHA during the study period.
The study's main goal was to investigate HCWs' knowledge, attitude, and practice toward the COVID-19 vaccine in DHA, UAE. Legislation and regulation remain essential for governance, assuring health care professionals promote and build vaccine confidence, contributing to herd immunity. Governments should strategize and plan to build vaccine confidence as it will affect citizens, HCWs, regulators, providers, payers, and patients. Further research is needed to explore the extent to which policy frameworks apply to innovations in health care, such as building vaccine confidence among HCWs.

Limitation and Study Strength
The study is one of the first to examine HCW's acceptance of COVID-19 vaccinations in Dubai. It is anticipated that this study will provide baseline data for further future vaccine hesitancy research. Especially with the merging of new pandemics and vaccine acceptance, this study has the advantage of including a large number of independent variables. In conclusion, we found a number of statistically significant associations that may help us understand HCW hesitancy toward COVID-19 vaccines better. Furthermore, our population was diverse with both genders and different age groups represented, as well as different marital statuses, occupations, and practice types.
As a limitation of the study, it did not reflect the knowledge, practice, and attitudes of health care providers working in hospitals, especially those in infectious disease and intensive care units, who may have a different acceptance level. In our study, we did not include administrative staff such as receptionists who work at primary health care centers, who may have different attitudes. In this study, limited information was captured, and further investigation is necessary in order to better understand the attitudes and knowledge of those who do not recommend vaccines to others, as they will have a significant effect on the community's acceptance of vaccines, as health care providers consider them to be trusted sources of information. A multivariate analysis of each category and their behavior and use of the vaccine is lacking. A further exploration of each category's knowledge and limitation is necessary in order to advocate for vaccines and to learn more about contraindications, which were continuously updated to a minimum group not to receive vaccines after some time.

Conclusion
Health care providers being in direct contact and whiteness, all the comorbidities and complications are reflected in a high vaccination rate. This study demonstrates a trust in information and messages from higher authorities and in data regarding the vaccine. The information found in this study will provide an understanding of the challenges associated with vaccine acceptance and how we can overcome these challenges in the event of a future pandemic. In the future, a study should be conducted to determine whether health care providers accept booster doses of the COVID-19 vaccine after changes in the pandemic, morbidity, mortality rate, and reinfection rates.

Contribution to the Field
The primary purpose of the research was to look at health care professionals' knowledge, attitudes, and practices about the COVID-19 vaccine in the DHA, UAE. Legislation and regulation will continue to be essential for governance, ensuring that health care professionals promote and increase vaccination trust, which will help boost herd immunity. If governments do not strategize and prepare to increase vaccination trust, citizens, HCWs, regulators, providers, payers, and patients will be affected. More study is required to see how policy frameworks affect health care innovations like increasing vaccination confidence among health care personnel.