1013303

research-article2021
JPCXXX10.1177/21501327211013303Journal of Primary Care & Community HealthFares et al.

Original Research
Journal of Primary Care & Community Health

COVID-19 Vaccination Perception

Volume 12: 1–9
© The Author(s) 2021
Article reuse guidelines:
and Attitude among Healthcare sagepub.com/journals-permissions
DOI: 10.1177/21501327211013303
https://doi.org/10.1177/21501327211013303

Workers in Egypt journals.sagepub.com/home/jpc

Samar Fares1 , Merihan M. Elmnyer2, Shimaa Sabry Mohamed2,

and Radwa Elsayed1

Abstract
Introduction: COVID-19 pandemic has affected the whole world, especially the frontline worriers. To get shielded
through this war, the world is racing to reach and manufacture COVID-19 vaccines. Vaccination hesitancy is one of the
significant obstacles to global health. Objectives: This study aimed to assess the perception and attitude of healthcare
workers in Egypt toward COVID-19 vaccines, acknowledge the determinants of their attitude, and the factors that could
increase the acceptance of the vaccine. Methods: an observational web-based anonymous survey was conducted on 385
Egyptian healthcare workers in different governorates. The questionnaire-based on Vaccine Hesitancy Survey Questions
of the World Health Organization was available in Arabic and English languages and was tested for reliability. Results:
Regarding vaccination decision, 51% of the participants were undecided, 28% refused, and 21% accepted vaccination.
Reasons for vaccine acceptance mainly were risks of COVID-19 (93%), safety (57.5%), and effectiveness (56.25%) of the
vaccine. Simultaneously, the reasons for vaccine hesitancy were the absence of enough clinical trials (92.4%) and fear of
side effects of the vaccine (91.4%). The leading factor that could increase vaccination acceptance among the participants
was to get sufficient and accurate information about the available vaccines. The participants revealed a high mean level of
concern for COVID-19 vaccines’ safety (3.8 of 5) that differs significantly among the different study groups (P-value .002).
Conclusion: Despite the COVID-19 pandemic, only approximately 21% of Egyptian healthcare workers in our study
accepted the COVID-19 vaccination. Vaccine hesitancy represents a major barrier to implementing vaccination programs.

Keywords
COVID-19, vaccination hesitancy, vaccination attitude, pandemic, SARS-CoV-2

Dates received: 20 February 2021; revised: 6 April 2021; accepted: 7 April 2021.

Introduction Use Authorization (EUA) (3). The most distributed 6 can-

didate vaccines are currently in the 3rd phase trial. They
COVID-19 is the unpredicted strike in which the whole differ in composition, storage requirements, and effec-
world allied and armed with knowledge and discipline to tiveness (70.4%-95%). No serious adverse effects were
battle. Over 104 million confirmed cases of COVID-19 reported from those vaccines.3
and 2.29 million deaths until now (February 6, 2021), as As a result of the variability in COVID-19 vaccines,
reported by World Health Organization (WHO).1 Despite there are different directions, perceptions, and attitudes
the global preventive efforts (physical distancing, face- toward the vaccine. Those differences symbolize chal-
mask, travel constraints, and quarantine) to contain the lenges for governments and public health experts. WHO4
infection, COVID-19 is continuing with its devastating
consequences on health, life, and economics. The world’s
hopes are attached to a successful preventive measure 1
Cairo University, Cairo, Egypt
that is the vaccination which has proved its capability to 2
Egyptian Ministry of Health, Mansoura, Egypt
stop infections and save lives over the years. Near the end
Corresponding Author:
of 2020, several vaccines started to arise; there are about Radwa Elsayed, Lecturer of Family Medicine Department, Cairo
100 candidate vaccines.2 Several vaccines are in the clini- University, 15 May City, Cairo 002, Egypt.
cal trial phases, and few have already gained Emergency Email: [email protected]

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use,
reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open
Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
2 Journal of Primary Care & Community Health 

declared vaccination hesitancy as one of the top 10 obsta- Study design and population
cles for global health. The currently building literature
sheds light on the COVID-19 vaccination hesitancy chal- This web-based survey was conducted on the healthcare
lenge. Several reports from the United States of America workers in Egypt. Healthcare workers are “all people
(USA), China, the United Kingdom, Ireland, and Congo engaged in actions whose primary intent is to enhance
revealed varied population and healthcare workers’ vacci- health,” as defined by WHO. We included physicians,
nation acceptance and hesitancy.5-9 pharmacists, physiotherapists, dentists, and nursing staff.
In Egypt, there have been 169 640 confirmed cases of All healthcare workers of all Egyptian governorates were
COVID-19, with 9651 deaths till now (February 8, 2021).1 invited to participate in the study.
The Egyptian government exerts great efforts to provide the
COVID-19 vaccines and sort the vaccination as a priority Sample size
for healthcare workers (HCWs) and older people, especially
with chronic diseases. To overcome the expected upcoming We calculated the required sample size using Stata statisti-
challenge of vaccination hesitancy, we have to measure it cal software version 16. We assumed the population size
and know the exact reasons behind it. (current healthcare workers in Egypt) to be 375 thousand as
In this study, we are targeting the healthcare workers to provided by the most recent report of The Central Agency
measure their perception and attitude toward the COVID- for Public Mobilization and Statistics (CAPMAS).10 The
19 vaccines. We selected the healthcare workers group as proportion of the sample with the expected outcome (vac-
our study population because they are among the priority cination acceptance) is 50%, based on recently published
groups for COVID-19 vaccination. Also, healthcare work- literature.11 With a margin of error ±0.5% and a confidence
ers represent the guidance and the trusted source of infor- level of 95%, the estimated required sample size is 384.
mation of the vaccine for the general population. They can
shield against misleading and confusing information. So, Study tool
their attitude will impact their and others’ health. To our
knowledge, this is the first study in Egypt aiming to deter- The study tool was provided to the participants in 2 lan-
mine the perception and attitude of healthcare workers, guages: Arabic and English versions. The questionnaire is
recognize the determinants of their attitude, and factors based on Vaccine Hesitancy Survey Questions by the SAGE
that could help to increase vaccine acceptance among working group on vaccination hesitancy (WHO),12 and
healthcare workers. This study represents a guide for health adapted to suit the current research objectives. Experts
authorities and public health experts in Egypt to highlight checked the consistency, objectivity, and language clarity of
the expected challenges for COVID-19 vaccination. the Arabic and English versions. A pilot of 30 participants
was invited for each version of the questionnaire, and then
reliability testing was done. Cronbach alpha was 0.684 and
Methods 0.618 for perception and attitude sections of the Arabic ver-
sion, respectively, and 0.638, 0.571 for perception and atti-
We conducted an observational web-based anonymous tude sections of the English version, respectively.
survey. The questionnaire was designed using Google Most of the questions were in the form of “yes and no”
Forms and distributed electronically. Data were collected questions except for few questions with a third option of “I
from December 2020 to January 2021 using the most pop- don’t know,” one five-point rating scale question, and few
ular online groups of healthcare workers on Facebook and open-ended questions for participants to express their rea-
WhatsApp in Egypt. Participants were recruited through sons openly. The questionnaire covered the following parts:
different online providers for different governorates to Firstly, it covered socio-demographic information,
avoid coverage bias and to be a representative sample. including age, sex, governorate, educational degree, and
specialty. The participants were also asked if they were
working in COVID-19 isolation hospital and if they were
Ethical considerations
dealing directly with COVID-19 patients, also, the own pre-
This study was approved by the Research and Ethics vious history of COVID-19 diagnosis.
Committee (REC) of Kasralainy faculty of medicine, Cairo Secondly, it discussed COVID-19 vaccination percep-
University (ID: 2021-N-13). Participation was entirely tion and attitude (18 questions), asking about sufficiency,
voluntary. Anonymity and confidentiality were kept as the trust, sources of information of COVID-19 vaccines, also,
study was conducted through a web-based anonymous sur- their perception of the risks of COVID-19 disease. The
vey. Electronic informed consent was obtained from all par- pharmaceutical companies and vaccine producers’ pri-
ticipants through a required question at the beginning of the mary interest, trust, and transparency in discussing the
survey after explaining the objectives and aim. side effects were also asked questions. The level of the
Fares et al. 3

participants’ concern of vaccine safety was asked, and the We found that gender and dealing directly with COVID-
response was recorded on a five-point rating scale (1 “Not 19 patients are notably significant factors with a P-value
concerned,” 2 “Mildly concerned,” 3 “Moderately con- <.001. Surprisingly, age, governorates, job, educational
cerned,” 4 “Considerably concerned,” 5 “Highly con- degree, working in a COVID-19 isolation hospital, and
cerned”). The survey questioned the participants’ attitude being diagnosed as COVID-19 suspected or confirmed
toward non-obligatory vaccine in general if its cost could patients were not significant factors for COVID-19 vacci-
affect their decision, COVID-19 vaccine recommenda- nation decision with P-value .864, .602, .237, .258, .599,
tions to others—finally, the decision to receive COVID-19 and .258, respectively.
vaccine with 3 options either yes, no, or undecided. (NB. As shown in Table 2, most responders (75.06%) did not
The term vaccine hesitancy refers to “delay in acceptance get sufficient information about the COVID-19 vaccine,
or refusal of vaccines despite availability of vaccination and 79% do not trust their information. Colleagues, social
services” as defined by WHO. Still, it was used variably in media, and published scientific articles were respectively
various studies. In our study, we used the term hesitant for the most common sources of information. Nearly 92%
the undecided group). accepted that COVID-19 is a dangerous disease.
Thirdly, the participants were asked for the reasons Being vaccinated would help build immunity, and if
behind their vaccination decision. it is a community responsibility to get vaccinated were
Fourthly, the participants refusing and hesitant to take significantly associated with the vaccination decision
the COVID-19 vaccine were asked about the factors that (P-value <.001 and <.001, respectively). Celebrities and
could help to increase the vaccination acceptance from their leaders’ advocation of the COVID-19 vaccine would not
point of view. affect the participants’ decision to get the vaccine (69.3%).
Furthermore, for recommending the COVID-19 vaccine
for family, friends, or patients, the responses went to no
Statistical analysis
(57.9%) and yes (42.08%), which was also a significantly
Categorical variables were described in numbers and per- associated factor with the vaccination decision.
centages, while numerical variables in mean and standard Hearing about bad reactions of COVID-19 vaccine
deviation. Association of participants’ perception and atti- (P = .002) was significantly important in the decision. Also,
tude with their decision regarding COVID-19 vaccination 52.7% of participants agreed that this reaction affected their
were done using Chi-Square test. Significant variables vaccination decision.
were tested using univariate multinomial regression. Regarding authorities’ and vaccine producers’ attitude,
Then we controlled for specific confounders (age, sex, trusting that vaccine producers are interested primarily in
governorate, job, degree, working in an isolation hospital, patient's health or that pharmaceutical companies could
dealing directly with COVID-19 patients, own previous produce safe and effective vaccines were most answered by
history of COVID-19 diagnosis), and multivariate multi- “I don’t know.” When asking if information about the side
nomial regression was done. For testing the level of con- effects is discussed openly by authorities, the majority went
cern about COVID-19 vaccines’ safety difference among to “no” (62.3%), then “I do not know” (25.1%). Their hos-
the 3 groups (accepting, refusing, and hesitant), we used pitals or centers advised about 54.2 % of participants to
one-way ANOVA. accept the vaccine.
Table 3 shows the multinomial regression analysis
results for the decision determinants for COVID-19 vacci-
Results
nation in the accepting (Yes) and refusing (No) groups com-
A total of 385 responses were received, representing a ran- pared to the hesitant group.
dom sample of the healthcare workers from different gover- For the accepting group, being male and dealing directly
norates in Egypt. with COVID-19 patients showed nearly 3 times higher odds
The majority of the responses regarding COVID 19 vac- of accepting the vaccination compared to females and those
cination decision reported undecided (51%), while 28% and who are not dealing directly (OR 3.11 and 2.28, 95% CI
21% decided no and yes, respectively. 1.59-6.10 and 1.28-4.08, 0.001 and 0.005, respectively).
As listed in Table 1. The majority of our participants Participants who took non-compulsory vaccines and those
were females in the 17 to 35 age group, living in different who recommended COVID-19 vaccination to others were 3
governorates. Nearly half of the participants were physi- and 17 times more likely to accept COVID-19 vaccination
cians. About 60% of participants had post-graduate studies. (OR 2.55 and 16.55, 95% CI 1.38-4.70 and 6.92-39.59,
More than 40% of the participants were working in COVID- 0.003 and <0.001, respectively). Participants who received
19 isolation hospitals or dealing directly with COVID-19 advice from their hospitals to get the vaccine had 2.5 higher
patients. About 37.66% of the participants were previously odds to accept the vaccine (OR 2.45, 95% CI 1.33-4.51,
diagnosed as COVID-19 cases. 0.004). Participants showed trust in vaccine producers,
4 Journal of Primary Care & Community Health 

Table 1.  Participant’s Characteristics and Association with COVID-19 Vaccination Decision (n = 385).

Yes Undecided No

  Total n (%) n (%) n (%) n (%) P-value*

Age group
 17-35 271 (70.39) 57 (21.03) 137 (50.55) 77 (28.41) .864
 36-66 114 (29.61) 23 (20.18) 61 (53.51) 30 (26.32)
Gender
 Female 313 (81.30) 52 (16.61) 171 (54.63) 90 (28.75) <.001
 Male 72 (18.70) 28 (38.89) 27 (37.50) 17 (23.61)
Governorate
 Cairo 102 (26.49) 26 (25.49) 52 (50.98) 24 (23.53) .602
 Dakahlia 114 (29.61) 19 (16.67) 62 (54.39) 33 (28.95)
 Giza 47 (12.21) 12 (25.53) 25 (53.19) 10 (21.28)
 Damietta 46 (11.95) 9 (19.57) 21 (45.65) 16 (34.78)
 Menofia 10 (2.60) 2 (20.00) 3 (30.00) 5 (50.00)
 Others 66 (17.14) 12 (18.18) 35 (53.03) 19 (28.79)
Job
 Physician 192 (49.87) 47 (24.48) 98 (51.04) 47 (24.48) .237
  Nursing Staff 89 (23.12) 10 (11.24) 50 (56.18) 29 (32.58)
 Pharmacist 87 (22.60) 21 (24.14) 39 (44.83) 27 (31.03)
 Dentist 13 (3.38) 2 (15.38) 8 (61.54) 3 (23.08)
 Physiotherapist 4 (1.04) 0 (00.00) 3 (75.00) 1 (25.00)
Educational Degree
 Baccalaureate 154 (40.00) 28 (18.18) 78 (50.65) 48 (31.17) .258
degree
 Professional 35 (9.09) 7 (20.00) 13 (37.14) 15 (42.86)
Diploma
  Master’s degree 115 (29.87) 24 (20.87) 65 (56.52) 26 (22.61)
  MD degree 67 (17.40) 18 (26.87) 33 (49.25) 16 (23.88)
Working in the COVID-19 isolation hospital
 No 227 (58.96) 47 (20.70) 121 (53.30) 59 (25.99) .599
 Yes 158 (41.04) 33 (20.89) 77 (48.73) 48 (30.38)
Dealing directly with COVID-19 patients
 No 227 (58.96) 33 (14.54) 131 (57.71) 63 (27.75) .001
 Yes 158 (41.04) 47 (29.75) 67 (42.41) 44 (27.85)
Diagnosed as COVID-19 suspected or confirmed patient
 No 240 (62.34) 48 (20.00) 131 (54.58) 61 (25.42) .258
 Yes 145 (37.66) 32 (22.07) 67 (46.21) 46 (31.72)

*P-value is considered significant if <.05.

pharmaceutical companies, and authorities had higher odds As shown in Figure 1, reasons for vaccine acceptance
for vaccination acceptance (OR 10.79, 8.83, and 22.50, were found to be basically due to risks of COVID-19 (93%),
95% CI 5.02-23.18, 4.09-19.07, and 7.78-65.07, <0.001, followed by the safety of the vaccine (57.5%), the effec-
<0.001, and <0.001, respectively). tiveness of the vaccine (56.25%), traveling facilitation
For the refusing group, the participants who heard of (43.75%). While the reasons for vaccine hesitancy and
anyone with a bad reaction related to COVID-19 vaccina- refusing were lack of enough clinical trials (92.4%) and fear
tion were 2 times more likely to refuse the vaccine (OR of vaccine’s side effects (91.4%), as shown in Figure 2. The
2.19, 95% CI 1.31-3.64, 0.003) compared to those who did unknown protection and immunity duration and the rumors
not hear of it. Participants who did not trust pharmaceutical about the vaccine's available version in Egypt were also
companies to produce a safe and effective vaccine and who substantial hindering factors for vaccination acceptance.
did not believe that the side effects are discussed openly The leading factor that could increase vaccination accep-
were 2 and 3 times more likely to refuse COVID-19 vacci- tance among our study participants was to get sufficient
nation (OR 1.94 and 3.19, 95% CI 1.13-3.35 and 1.68-6.04, and accurate information about the available vaccines, as
0.017 and <0.001, respectively). revealed in Figure 3.
Fares et al. 5

Table 2.  COVID-19 Vaccination Perception and Attitude among Healthcare Workers in Egypt (n = 385).

Yes Undecided No

  Total n (%) n (%) n (%) n (%) P-value*

Getting sufficient information about the COVID-19 vaccine
 No 298 (75.06) 50 (17.30) 159 (55.02) 80 (27.68) .008
 Yes 96 (24.94) 30 (31.25) 39 (40.63) 27 (28.13)
Trusting the information about the COVID-19 vaccine
 No 305 (79.22) 40 (13.11) 173 (56.72) 92 (30.16) <.001
 Yes 80 (20.78) 40 (50.00) 25 (31.25) 15 (18.75)
The sources of information about the COVID-19 vaccine
  Published scientific articles 239 (62.08) 57 (23.85) 118 (49.37) 64 (26.78) .164
  Social media 299 (77.66) 56 (18.73) 153 (51.17) 90 (30.10) .071
  Mass media 206 (53.51) 45 (21.84) 110 (53.40) 51 (24.76) .360
 Colleagues 304 (78.96) 62 (20.39) 161 (52.96) 81 (26.64) .485
 Others 80 (20.78) 17 (21.25) 42 (52.50) 21 (26.25) .942
COVID-19 is a dangerous disease
 No 29 (7.53) 7 (24.14) 15 (51.72) 7 (24.14) .852
 Yes 356 (92.47) 73 (20.51) 183 (51.40) 100 (28.09)
Needing the vaccine to build your immunity
 No 186 (48.31) 10 (5.38) 85 (45.70) 91 (48.92) <.001
 Yes 199 (51.69) 70 (35.18) 113 (56.78) 16 (8.04)
It is a community responsibility to get vaccinated.
 No 160 (41.56) 8 (5.00) 67 (41.88) 85 (53.13) <.001
 Yes 225 (58.44) 72 (32.00) 131 (58.22) 22 (9.78)
Celebrities’ or leaders’ advocation of COVID-19 vaccination could affect your decision.
 No 267 (69.35) 35 (13.11) 134 (50.19) 98 (36.70) <.001
 Yes 118 (30.65) 45 (38.14) 64 (54.24) 9 (7.63)
Recommending COVID-19 vaccination for family, friends, or patients
 No 223 (57.92) 7 (3.14) 119 (53.36) 97 (43.50) <.001
 Yes 162 (42.08) 73 (45.06) 79 (48.77) 10 (6.17)
Getting non-obligatory vaccinations
 No 188 (48.83) 24 (12.77) 100 (53.19) 64 (34.04) <.001
 Yes 197 (51.17) 56 (28.43) 98 (49.75) 43 (21.83)
The vaccination cost could affect your decision of vaccination.
 No 276 (71.69) 51 (18.48) 139 (50.36) 86 (31.16) .035
 Yes 109 (28.31) 29 (26.61) 59 (54.13) 21 (19.27)
Hearing of anyone with a bad reaction related to COVID-19 vaccination
 No 196 (50.91) 46 (23.47) 111 (56.63) 39 (19.90) .002
 Yes 189 (49.09) 34 (17.99) 87 (46.03) 68 (35.98)
This situation affected your decision for the COVID-19 vaccination.
 No 148 (47.28) 38 (25.68) 68 (45.95) 42 (28.38) .104
 Yes 165 (52.72) 28 (16.97) 93 (56.36) 44 (26.67)
Your hospital or medical center advice to get the vaccine
 No 176 (45.71) 24 (13.64) 92 (52.27) 60 (34.09) .002
 Yes 209 (54.29) 56 (26.79) 106 (50.72) 47 (22.49)
The vaccine producers are interested primarily in your health.
  I do not know 192 (49.87) 18 (9.38) 110 (57.29) 64 (33.33) <.001
 No 70 (18.18) 7 (10.00) 35 (50.00) 28 (40.00)
 Yes 123 (31.95) 55 (44.72) 53 (43.09) 15 (12.20)
Trusting the pharmaceutical companies for producing a safe and effective vaccine
  I do not know 159 (41.30) 19 (11.95) 93 (58.49) 47 (29.56) <.001
 No 132 (34.29) 11 (8.33) 66 (50.00) 55 (41.67)
 Yes 94 (24.42) 50 (53.19) 39 (41.49) 5 (5.32)
Information about side effects is discussed openly by authorities.
  I do not know 97 (25.19) 12 (12.37) 66 (68.04) 19 (19.59) <.001
 No 240 (62.34) 36 (15.00) 123 (51.25) 81 (33.75)
 Yes 48 (12.47) 32 (66.67) 9 (18.75) 7 (14.58)

*P-value is considered significant if <.05.

6 Journal of Primary Care & Community Health 

Table 3.  Multinomial Logistic Regression for COVID-19 Vaccination Decision Determinants.

Yes No

Adjusted OR* Adjusted OR

  (95% CI) P# (95% CI) P
Gender (Male) 3.11 (1.59-6.10) .001 1.19 (0.59-2.39) .632
Dealing directly with COVID-19 patients (Yes) 2.28 (1.28-4.08) .005 1.43 (0.85-2.42) .181
Getting sufficient information about COVID-19 vaccine (Yes) 2.78 (1.45-5.30) .002 1.44 (0.79-2.63) .235
Trusting the information about COVID-19 vaccine (Yes) 9.18 (4.54-18.53) <.001 1.20 (0.57-2.49) .631
Needing the vaccine to build your immunity (Yes) 4.99 (2.29-10.86) <.001 0.10 (0.05-0.19) <.001
It is a community responsibility to get vaccinated (Yes) 3.69 (1.62-8.40) .002 0.10 (0.06-0.19) <.001
Leaders’ advocation of COVID-19 vaccination could affect your decision (Yes) 4.54 (2.38-8.64) <.001 0.15 (0.07-0.35) <.001
Recommending COVID-19 vaccination for others (Yes) 16.55 (6.92-39.59) <.001 0.12 (0.06-0.27) <.001
Getting non-obligatory vaccinations (Yes) 2.55 (1.38-4.70) .003 0.66 (0.39-1.10) .112
The vaccination cost could affect your decision of vaccination (Yes) 0.95 (0.52-1.74) .867 0.43 (0.23-0.79) .007
Heard of bad reaction related to COVID-19 vaccination (Yes) 0.84 (0.48-1.49) .554 2.19 (1.31-3.64) .003
Your hospital or medical center advice to get the vaccine (Yes) 2.45 (1.33-4.51) .004 0.62 (0.37-1.04) .069
The vaccine producers are interested primarily in health.
 No 1.17 (0.41-3.32) .774 1.83 (0.95-3.54) .071
 Yes 10.79 (5.02-23.18) <.001 0.42 (0.20-0.87) .019
Trusting the pharmaceuticals for a safe and effective vaccine
 No 0.80 (0.33-1.92) .612 1.94 (1.13-3.35) .017
 Yes 8.83 (4.09-19.07) <.001 0.23 (0.08-0.64) .005
Information about side effects is discussed openly by authorities.
 No 1.80 (0.82-3.96) .141 3.19 (1.68-6.04) <.001
 Yes 22.50 (7.78-65.07) <.001 3.03 (0.94-9.70) .062

*OR: odds ratio.

95% CI: 95% confidence interval.
#P value is considered significant if ≤.05.

The participants showed a high level of concerns for workers to be only 28%.9 It also agreed with the study con-
COVID-19 vaccines safety (on a scale from 1 to 5) as 34.8% ducted in the USA with 36% acceptance and 56%
were highly concerned while only 4.6% revealed no con- hesitancy.13 Meanwhile, our findings were against the study
cerns. The mean level of concern differs significantly conducted in France, where 77.6% of participants “proba-
among the different groups, where it was 2.9 in the accept- bly agreed” to get vaccinated.14 Also, this disagreed with
ing group, 3.9 in the hesitant group, and 4.3 in the refusing Barry et al,15 who carried out a study to assess COVID-19
group (P-value .002). vaccine confidence in a MERS-CoV experienced nation
and found that two-thirds of HCWs expressed willingness
to receive a potential COVID-19 vaccine.
Discussion Regarding gender, the results agreed with other studies
Healthcare workers’ perception and attitude to COVID 19 where the odds of acceptance of vaccination among males
vaccines play an essential role in the general population’s were significantly higher compared to females.14 This could
vaccination behavior through their consultation. The diver- be explained by that nearly 60% of the males in the current
sity of representation from both genders, age groups, cate- study were physicians and dealing directly with COVID-19
gories in healthcare, and proximity in dealing with patients, which led to the high probability of vaccination
COVID-19 patients represents strength in this study. This acceptance. Dealing directly with COVID-19 patients led to
study represents a guide for health authorities and public 3 times higher odds of acceptance. This agreed with the
health experts in Egypt to enable them to maximize accep- study in the USA where HCWs who had not taken care of
tance of COVID-19 vaccination. COVID-19 patients had higher rates of vaccine refusal.13
In this study, only 21% of the participants agreed to get a Regarding the age, it was insignificantly associated with
vaccine against COVID-19, 28% disagreed, while nearly the decision of vaccination. This was incompatible with
half of the participants were in the undecided group. This Grech et al,11 where higher uptake of a COVID-19 vaccine
low acceptance agreed with the Congo study that found the was in the oldest age group as they are the more vulnerable
acceptance of COVID-19 vaccination among healthcare group and therefore more likely to accept the vaccine. In
Fares et al. 7

Figure 1.  Reasons of COVID-19 vaccination acceptance among healthcare workers.

Figure 2.  Reasons of vaccination refusal and vaccination hesitancy among healthcare workers.

this study, hesitancy related to the COVID-19 vaccine was COVID-19 vaccines, and 79% of them did not trust the
indifferent among categories of HCWs (P-value .237), dis- information they got. This was following the study in the
agreeing with the study revealing that hesitancy was greater USA where a high percentage of HCWs did not trust
among nurses than physicians.6 information about COVID-19 and its severity, also by the
In the current study, most of the respondents (75.06%) regulatory authorities and pharmaceutical companies for
believed that they did not get sufficient information about vaccine development and safety.13 Like other studies,
8 Journal of Primary Care & Community Health 

Figure 3.  Factors helping in vaccination acceptance.

colleagues, social media, and published scientific articles and 11% among those who were willing to get the vacci-
were respectively the most common sources of informa- nation. Concerns for vaccination safety, effectiveness, and
tion in this study.13 duration of trials and testing were common findings in
As a reflection of participants’ expected attitude toward many studies.5,13
COVID-19 vaccines, the researchers asked the participants The leading factor that could increase vaccination accep-
the non-obligatory vaccines and its cost. Participants who tance among this study participants was to get sufficient and
got non-obligatory vaccines were 3 times more likely to accurate information about the available vaccines. This
accept the COVID-19 vaccination, agreeing with other finding which revealed the major obstacle for vaccination
studies.11,13 The current study participants agreed with acceptance, actually represented the solution that could be
HCWs in the USA who were worried about the out-of- quickly adopted and provided by the authorities to maxi-
pocket cost of the COVID-19 vaccine.13 mize vaccination acceptance and coverage.
The participants who recommended COVID-19 vaccina- The governmental approval and recommendation of the
tion for others were 17 times more likely to accept COVID- vaccine was the third factor. This was in contrast with the
19 vaccination and 88% less likely to refuse vaccination. results of Qiao et al,17 where the hesitant college students
This agreed with the study carried by Shekhar et al,13 whose had greater scores on authoritative advice factors such as
study showed that HCWs who are vaccinated are more school/college, government, and doctors. This contrast may
likely to recommend vaccines to others. be referred to the different study population.
Regarding reasons of acceptance among those who Public health authorities and the government in Egypt
decided to receive the vaccine once it becomes available, have a heavy mission for implementing successful vaccina-
the risk associated with COVID-19 disease was the most tion programs with high coverage. WHO recommended
prevalent reason. While, for reasons of vaccination refusing prior planning for any vaccination program to ensure high
and hesitancy, the commonest reason was insufficient acceptance.18 A successful plan should adopt 2 main
knowledge about its safety and absence of enough clinical approaches; the first is prioritizing population categories in
trials. This was compatible with almost all studies done for need of vaccination that was already designed and declared
the assessment of COVID 19 vaccination hesitancy.6,11,14 by Egyptian authorities; the other highly impactful approach
In the current study, the participants showed a high is to alleviate any concerns related to vaccination and
level of concern for COVID-19 vaccine safety that dif- increase the awareness and demand of vaccination.19 The
fered significantly among the different groups. This agreed current study provides the authorities with deep insights
with Dodd et al16 study in Australia, where concern about into the expected obstacles, concerns, and approaches for
the vaccine's safety was 36% among the hesitancy group solutions to reach the desirable vaccination coverage.
Fares et al. 9

There are some limitations of the current study. Firstly, 5. Pogue K, Jensen J, Stancil C, et al. Influences on attitudes
the use of an online survey may result in sampling bias, but regarding potential COVID-19 vaccination in the United States.
this was the available way in the current situations. Notably, Vaccines (Basel). 2020;8:582. doi:10.3390/vaccines8040582
females and adults between 17 and 35 were over-represented 6. Gadoth A, Halbrook M, Martin-Blais R, et al. Cross-sectional
assessment of COVID-19 vaccine acceptance among health
in this study. It is also noteworthy that the assessment of
care workers in Los Angeles. Ann Intern Med. Published
intention to vaccinate in this study did not account for the
online February 9, 2021. doi:10.7326/m20-7580
other possible factors affecting vaccination decision, such as 7. Lin Y, Hu Z, Zhao Q, Alias H, Danaee M, Wong L.
duration of protection of the vaccine and the need for booster Understanding COVID-19 vaccine demand and hesitancy:
doses, which could influence participants’ decision. a nationwide online survey in China. PLoS Negl Trop Dis.
2020;14:e0008961. doi:10.1371/journal.pntd.0008961
8. Murphy J, Vallières F, Bentall R, et al. Psychological char-
Conclusion acteristics associated with COVID-19 vaccine hesitancy and
Despite the COVID-19 pandemic, only approximately 21% resistance in Ireland and the United Kingdom. Nat Commun.
of Egyptian healthcare workers in the current study accepted 2021;12:29. doi:10.1038/s41467-020-20226-9
to get COVID-19 vaccines. In the context of a pandemic, 9. Kabamba Nzaji M, Kabamba Ngombe L, Ngoie Mwamba G,
et al. Acceptability of vaccination against COVID-19 among
vaccine hesitancy represents a major barrier to implement-
healthcare workers in the Democratic Republic of the Congo.
ing vaccination programs. In this study, we concluded that
Pragmat Obs Res. 2020;11:103-109.
the absence of enough clinical trials and the fear of the vac- 10. CAPMAS, Egypt. Statistical yearbook. capmas.gov.eg.

cine's side effects were the significant reasons for vaccine Update 2019. Accessed January 2021. https://www.capmas.
hesitancy and refusal. The leading factor that could increase gov.eg/Pages/Publications.aspx?page_id=5104&Year=23479
vaccination acceptance was to get sufficient and accurate 11. Grech V, Gauci C, Agius S. Withdrawn: vaccine hesitancy
information about the available vaccines. The current study among Maltese Healthcare workers toward influenza and
provides the authorities with deep insights into the expected novel COVID-19 vaccination. Early Hum Dev. Published
obstacles, concerns, and approaches for solutions. online October 1, 2020.
12. World Health Organization. Vaccine hesitancy survey ques-
tions related to SAGE vaccine hesitancy matrix. who.int.
Declaration of Conflicting Interests
Update 2014. Accessed January 2021 https://www.who.int/
The author(s) declared the following potential conflicts of interest immunization/programmes_systems/Survey_Questions_
with respect to the research, authorship, and/or publication of this Hesitancy.pdf
article: The authors declare absence of conflicts of interest. 13. Shekhar R, Sheikh AB, Upadhyay S, et al. COVID-19 vac-
cine acceptance among health care workers in the United
Funding States. Vaccines (Basel). 2021;9:119. doi:10.3390/vaccines
9020119
The author(s) received no financial support for the research,
14. Detoc M, Bruel S, Frappe P, Tardy B, Botelho-Nevers E,
authorship, and/or publication of this article.
Gagneux-Brunon A. Intention to participate in a COVID-19
vaccine clinical trial and to get vaccinated against COVID-
ORCID iDs 19 in France during the pandemic. Vaccine. 2020;38:7002-
Samar Fares https://orcid.org/0000-0002-3438-1329 7006.
15. Barry M, Temsah M-H, Alhuzaimi A, et al. COVID-19 vaccine
Radwa Elsayed https://orcid.org/0000-0002-3219-3703
confidence and hesitancy among healthcare workers: a cross-sec-
tional survey from a MERS-CoV experienced nation. bioRxiv.
References Published online 2020. doi:10.1101/2020.12.09.20246447
1. World Health Organization. COVID-19 dashboard. who.int. 16. Dodd RH, Pickles K, Nickel B, et al. Concerns and motiva-
Update February 2021. Accessed February 6, 2021. https:// tions about COVID-19 vaccination. Lancet Infect Dis. 2021;
covid19.who.int/ 21:161-163.
2. World Health Organization. DRAFT landscape and tracker 17. Qiao S, Friedman DB, Tam CC, Zeng C, Li X. Vaccine accep-
of COVID-19 candidate vaccines. who.int. Update February tance among college students in South Carolina: do information
2021. Accessed February 12, 2021. https://www.who.int/ sources and trust in information make a difference? medRxiv.
publications/m/item/draft-landscape-of-covid-19-candidate- Published online 2020. doi:10.1101/2020.12.02.20242982
vaccines 18. World Health Organization. Tailoring immunization pro-

3. Ferbeyre G, Santiago Vispo N. The race for a coronavirus grammes. who.int. Update May 2018. Accessed February 17,
vaccine. Bionatura. 2020;5:1290-1292. doi:10.21931/rb/2020 2021. https://www.who.int/immunization/programmes_sys-
.05.04.1 tems/Global_TIP_overview_July2018.pdf?ua=1
4. World Health Organization. Ten threats to global health in 19. French J, Deshpande S, Evans W, Obregon R. Key guide-
2019. Who.int. Update February 2021. Accessed February 12, lines in developing a pre-emptive COVID-19 vaccination
2021. https://www.who.int/news-room/spotlight/ten-threats- uptake promotion strategy. Int J Environ Res Public Health.
to-global-health-in-2019 2020;17:5893.