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

Background: The coronavirus disease 2019 (COVID-19) pandemic is a major public health crisis worldwide. In less than 12 months since the World Health Organization declared the outbreak, several different COVID-19 vaccines have been approved and deployed mostly in developed countries since January 2021. However, hesitancy to accept the newly developed vaccines is a well-known public health challenge that needs to be addressed. The aim of this study was to measure willingness and hesitancy toward COVID-19 vaccines among health care practitioners' (HCPs) in Saudi Arabia. Methods: A cross-sectional study using an online self-reported survey was conducted among HCPs in Saudi Arabia between April 4th to April 25th 2021 using snowball sampling. Multivariate logistic regression was employed to identify the possible factors affecting HCPs’ willingness and hesitancy to receive COVID-19 vaccines. Results: Out of 776 participants who started the survey, 505 (65%) completed it and were included in the results. Among all HCPs, 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%) already received the COVID-19 vaccine, and 48 (9.50%) were registered to receive it. The main reason of agreement to receive the COVID-19 vaccine was “wanting to protect self and others from getting the infection” (24%). Conclusion: Our findings have shown that hesitancy toward receiving COVID-19 vaccines among HCPs in Saudi Arabia is limited and therefore may not be a serious issue. The outcomes of this study may 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 uptake of these vaccines.


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  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.

Design
We conducted a cross-sectional study to assess willingness and hesitancy toward COVID-19 vaccines among HCPs in KSA. We created an online self-reported survey using the Question Pro survey tool hosted at Imam Abdulrahman Bin Faisal University (IAU). The survey was offered only in English because most of the HCPs in Saudi speak and understand English. The questions asked in the survey are available as part of the underlying data. 37 Responses were collected anonymously and no personally identifying information was collected. This study was approved by the IAU's Institutional Review Board (IRB-2021-03-149).

REVISED Amendments from Version 5
In this version we repeated the statistical analysis for Table 3 using Mann Whitney U-Test instead of using Chi square test.
Any further responses from the reviewers can be found at the end of the article

Sampling
We started the data collection via convenience sampling to HCPs and via hospital's email lists. Also, the survey was distributed via online links posted on social media platforms (e.g., Twitter, LinkedIn, and WhatsApp). In addition, we shared the survey link with multiple health care organizations, scientific societies, and associations to send it to their HCPs/members and encourage them to further share it to reach the target population. Data were collected from April 4 th to April 25 th 2021.

Participants
All HCPs currently working in healthcare facilities in KSA, regardless of the level of patient contact and their clinical role, were eligible to participate in the study. Informed consent was obtained from all the participants prior to starting the survey. A participation consent statement was added on the study information page as follows: "If you are a health care practitioner in Saudi Arabia and consent to participate in this survey, please proceed to the next page to start the survey." Only those who agreed to participate where allowed to complete the survey. Proceeding to the survey page was therefore taken as consent to participate.

Measures
The survey collected participants' demographics and health information and assessed HCPs' attitude and perception of COVID-19 and COVID-19 vaccines. Furthermore, the survey assessed the HCPs' willingness to receive COVID-19 vaccines as well as hesitancy level as measured by the vaccine hesitancy scale (VHS). The VHS includes 10 items measured on a 5-point Likert scale ranging from strongly disagree to strongly agree. The VHS is developed by the WHO Strategic Advisory Group of Experts (SAGE) to capture parental attitudes, beliefs, and behaviors surrounding vaccination. 23 The COVID-19 vaccines hesitancy scale, 24 which was adopted in this study, is a modified version of the VHS. The validity and reliability of the COVID-19 VHS was established in another study. 24 However, we pre tested the survey with nine HCPs currently practicing in KSA to assure the clarity of the questions and to evaluate the face validity of the scale. The internal consistency of the scale used in this study was assessed by Cronbach's alpha (0.75).

Statistical analysis
For descriptive analysis, frequency count and percentages were calculated and presented in a table format. A bivariate analysis to evaluate the associations between HCP's willingness to the receive COVID-19 vaccines and their demographic characteristics, awareness, and health status was done using Chi-Square/Fisher Exact where appropriate. The differences in the VHS scores between the participants who reported their willingness to receive the vaccine and those who had no intention to receive the vaccine were determined through Mann Whitney U-Test. Responses about willingness to receive the vaccine (item 10 of the VHS) were set as the dependent variable while all the other 9 items of the VHS were set as the independent variable. All analyses were performed using SPSS 26.0 (IBM Corporation, New York, NY, United States). The level of statistical significance was set at p < 0.05 for this analysis.

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 AE 1.17, p < 0.001) and it will be effective in preventing the infection (2.75 AE 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 AE 1.08, p < 0.001 and 4.22 AE 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 AE 1.16, p < 0.001) and were worried about the side effects of the vaccines (2.91 AE 1.08, p < 0.001). The difference between the VHS scores were significantly different throughout the VHS items (see Table 3).

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  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: 1) Perceived their health status as excellent or very good; and 2) Believed that vaccines will relieve the pandemic.
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. 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 crosssectional 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. We have mentioned in the statistical analysis section (revised) that bivariate analysis was done between the variables. The dependent variable is the response of the participants who showed willingness to receive the COVID-19 vaccine (responded with YES for item #10 of the VHS) and the independent variables were the VHS 9 items using Chi-Square test. We did not run Regression analysis. We only did the Chi-Square for associations.
Also, we stated the dependent variable below table 3 for clarification.
Thank You.

Methods
The main sampling method was convenience. I am not sure how the authors can verify the snowballing sampling?

Statistical analysis
Please clarify that the multivariable regression model was logistic regression.

Results
Did the authors conduct the validity or reliability tests such as Cronbach alpha? If yes, include them in a table if no add this to the limitation section. 3-Please also state the inclusion and exclusion criteria for these participants in this survey. Selection bias may exist if the participants with small sample size were recruited without reasonable inclusion and exclusion criteria.
We have mentioned the inclusion criteria for this study in the Participants section "All HCPs currently working in healthcare facilities in KSA, regardless of the level of patient contact and their clinical role, were eligible to participate in the study." No exclusion criteria were stated.

4-
The study was conducted in April, 2021, but the pandemic situation and vaccination policies changed greatly during this year. This change always influenced people's attitudes towards COVID-19 vaccination, and therefore the conclusion might be changed.
Yes, agree. We aimed to investigate vaccine acceptance in Saudi Arabia wright after the approval of the COVID-19 vaccines. Prior studies were already conducted before this milestone which provided different prospective and conclusion. However, more studies need to be conducted after the changes in the pandemic situation and the policies which have influenced HCPs' attitude toward the vaccines.

Thank You.
Here are some comments for improvement. I hope these comments are useful! Title: your study aims to measure willingness and hesitancy toward COVID-19 vaccines among health care practitioners (HCPs) in Saudi Arabia. However, "willingness" is conspicuously absent from the title; I suggest adding the willingness to the title.

Introduction
Due to massive changes in the number of cases every day, mentioning the date you got the statistics increases the accuracy for the readers. The problem statement in the introduction needs to be enriching more by mentioning: The impact of COVID-19 on HCPs by presenting governmental statistics and previous studies

Methods
In the Participant's part, you mentioned "All adults (>18 years of age) currently working in healthcare facilities in KSA" while your investigation is among HCPs! …This may confuse the readers.

○
In the Measures part, you wrote "we piloted the survey with nine HCPs currently practicing in KSA to assure the clarity of the questions and to evaluate the face and content validity of the scale on the targeted population", did you mean pre-test? Because you examined the face and content validity, however, the pilot study investigates the reliability of the scale by Cronbach's alpha, and the minimal size to conduct it is 30 participants.

Results
You wrote "Women were more hesitant to receive the vaccine (47.3%) compared to men". While Table 2 shows the willingness to receive the COVID-19 vaccines. There is a difference between willingness and hesitancy. I would change this to "Women were less willing to receive the vaccine".

Discussion
Well written and interesting, however, it is better to focus on the conspiracy theories in your introduction to enrich your problem statement in this study.

○
It is better to add the limitations and future studies in separate parts after the discussion. ○ Lastly, please revise the manuscript for flow and English language edits and update any references Again, thank you for your work, and good luck. MAG Regards,