COVID-19 Vaccine Acceptance and Hesitancy Among Health Care Workers in Lebanon

Background Lebanon endured its worst economic and financial crisis in 2020–2021. To minimize the impact of COVID-19 pandemic, it is important to improve the overall COVID-19 vaccination rate. Given that vaccine hesitancy among health care workers (HCWs) affects the general population’s decision to be vaccinated, our study assessed COVID-19 vaccine acceptance among Lebanon HCWs and identified barriers, demographic differences, and the most trusted sources of COVID-19 information. Methods A cross-sectional study was conducted between January and May 2021 among HCWs across nine hospitals, the Orders of Physicians, Nurses, and Pharmacists in Lebanon. Descriptive statistics were performed to evaluate the COVID-19 vaccine acceptance, and univariate and multivariable to identify their predictors. Results Among 879 participants, 762 (86.8%) were willing to receive the COVID-19 vaccine, 52 (5.9%) refused, and 64 (7.3%) were undecided. Males (226/254; 88.9%) and those ≥ 55 years (95/100; 95%) had the highest rates of acceptance. Of the 113 who were not willing to receive the vaccine, 54.9% reported that the vaccine was not studied well enough. Participants with a previous SARS-CoV-2 infection and those who did not know if they had a previous infection (p = 0.002) were less likely to accept the vaccine compared to those with no previous infection. The most trusted COVID-19 sources of information were WHO (69.3%) and healthcare providers (68%). Conclusion Lebanese HCWs had a relatively high acceptance rate for COVID-19 vaccination compared to other countries. Our findings are important in informing the Lebanese health care authorities to establish programs and interventions to improve vaccine uptake among HCWs and the general population. Supplementary Information The online version contains supplementary material available at 10.1007/s44197-023-00086-4.


Introduction
The coronavirus disease-2019 (COVID- 19) pandemic has resulted in more than 500 million confirmed cases and over 6.2 million deaths (as of May 2022) [1]. While the COVID-19 pandemic has had detrimental health, cultural, and socioeconomic effects across all countries, low-and middleincome countries (LMICs), such as Lebanon, are at greater risk of infection [2]. The first case of COVID-19 in Lebanon was confirmed on February 21st, 2020, and since then, the number of cases and deaths has significantly grown [3,4].
Enormous international efforts have been put in the development and distribution of COVID-19 vaccines. The COVID-19 Vaccines Global Access Facility (COVAX) was launched [5], in collaboration with the World Health Organization (WHO), with a goal of administering at least two billion COVID-19 vaccine doses across LMICs by 2022 [6][7][8].
In Lebanon, the Ministry of Public Health (MOPH) launched its vaccination rollout on February 14th, 2021, starting with the Pfizer-BioNTech mRNA vaccine. An additional 1.5 million doses were reserved from Oxford-AstraZeneca to speed up the distribution of vaccines [7]. However, the success of immunization campaigns depends on acceptance of newly introduced vaccines, particularly during pandemics [9]. Vaccine hesitancy remains a pertinent issue across the general populations as well as among health care workers (HCWs), globally. Vaccine acceptance is known to vary with time and context [10]. Therefore, vaccine acceptance of a newly developed vaccines, especially as novel technology (e.g., mRNA vaccines) is being implemented, has historically been a concern [11].
Due to the limited vaccine supply across the world, priority was given to HCWs and other front-line workers to be immunized first. One of the major concerns was the level of vaccine acceptance across these HCWs [12]. An international survey on COVID-19 vaccine acceptance, conducted from June 16 to June 20, 2020, showed that at least 30% would be hesitant to take the vaccine [11]. A survey conducted in April 2020 in the United States (US) estimated refusal of COVID-19 vaccination in at least one third of the participants [13]. A national survey conducted between October and December 2020 in the Kingdom of Saudi Arabia (KSA) showed that the acceptance of COVID-19 vaccine among HCWs was around 65%, with the main reason for hesitance being fear of possible side effects [14]. In addition to several other vaccine acceptance studies [15][16][17][18][19][20], the KSA study highlighted the need to understand the factors that were likely to impact the decision of HCWs to receive the vaccine, especially with the expectation that new strains will continuously evolve and vaccine efficacy may declinemaking new vaccine uptake a major contributor to herd immunity over time [10].
Many factors, including widely spread misinformation, can be important contributors, adversely affecting vaccine acceptance [12]. Because HCWs are regarded as a trusted source of information and advice to their patients and acquaintances, it is crucial to highlight their role in spreading awareness and advocating for vaccine acceptance [21]. While various findings have been disseminated regarding the COVID-19 vaccine, factors associated with vaccine refusal have not been studied well among HCWs in Lebanon. Halabi et al. reported a refusal rate of 40% among the Lebanese general population, with female gender, marriage status, and history of vaccine hesitancy being the most influencing factors [22].
Understanding the potential reasons for COVID-19 vaccine refusal among HCWs in Lebanon may help in identifying ways to overcome vaccine gaps in the health care sector and the general population, and improve strategic plans in containing the Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) [22]. Given the paucity of information about Lebanese HCWs' acceptance of COVID-19 vaccines and associated demographic factors, we conducted a survey among HCWs from several Lebanese health care institutions to examine COVID-19 vaccine acceptance and identify factors leading to COVID-19 vaccine refusal.

Program Description and Setting
Between January and May 2021, we used selective sampling to conduct a cross-sectional survey using an electronic questionnaire via Qualtrics ® (Qualtrics, Provo, UT). HCWs at nine participating hospitals across different provinces in Lebanon were invited as well as other HCWs registered in Orders of Physicians, Nurses, and Pharmacists.
The survey was distributed to HCWs by email, WhatsApp message, or Short Message Service (SMS). The eligibility requirements to participate in the study included being a HCW, 18 years or older, read English or Arabic, and have access to the Internet. Participants had the option to choose English or Arabic. E-consent was required prior to data collection. Our target population included approximately 20,000 physicians, residents, fellows, medical students, nurses (practical and registered nurses), dietitians, dentists, optometrists, psychologists, respiratory therapists, physical therapists, occupational therapists, behavioral therapists, social workers, infection control workers, pharmacists, laboratory and radiology technicians, research assistants and coordinators, and administrative personnel. Based on our previous work and published study [20], and considering the Lebanese HCW population at approximately 40,000 [23], with a vaccine acceptance of 50% and margin of error of 4% (95% CI 46-54%), we calculated a sample size of 592 individuals.

Measures and Variables
Our survey was redesigned from a previously published work conducted by Malik et al. [20], and included 20 questions (Supplementary Material). Basic demographic information, in addition to information pertaining to participants' country of origin and religious association were collected. We asked participants to identify factors such as religious barriers, concerns about side effects, lack of trust in vaccine production, and disbelief in vaccine potency that might influence their decision when answering "No" or "Don't know" about their willingness to receive COVID-19 vaccine once available. Lastly, HCWs were asked about their confidence in organizations and healthcare providers and reliability in media sources as it pertains to disseminating COVID-19 information, with these variables being assigned a value of either 0 or 1 (0 = Very Little/Little/Some/Don't Know; 1 = Much/Very Much).
The Institutional Review Boards (IRB) at Yale University (IRB protocol number: 2000029237), and at American University of Beirut Medical Center (IRB protocol number: SBS-2020-0563) approved this study, in line with the Code of Ethics of the World Medical Association, the Declaration of Helsinki [24]. After we informed the subjects about the purpose of the study, E-consent was required prior to data collection. Participants were also informed that there will be no risks or direct benefits from their collaboration to this study. The participation was completely voluntary and enrolled subjects retained right to withdraw at any time throughout the study. In addition, to maintain confidentiality, the research team do not have access to their names or contact details. Data were secured on a password protected computer and will only be accessible to the research team members, after which the data will be deleted once the legal retention period expired.

Statistical Analysis
Collected data were coded and entered in the software Statistical Package for Social Sciences (SPSS) version 25 (SPSSTM Inc., Chicago, IL United States). Descriptive statistics were conducted to identify the sample demographic characteristics. Moreover, we calculated the frequency and percentage of responses to questions related to COVID-19 vaccine acceptance, reasons for refusal to accept a COVID-19 vaccine, reliability of media sources, and confidence in organizations and healthcare providers.
Finally, univariate analyses were conducted. The explanatory variables were first tested 1 by 1 against the dependent variable for the presence of a significant association using the binomial logistic regression. In the multivariable logistic regression model, we included variables reported in the literature to be associated with COVID-19 vaccine acceptance considering them as potential confounders, such as age, gender, religious association, and educational level [11,14,20,[25][26][27], and variables that showed a significant association at p ≤ 0.05 across any categories in the univariate analysis. The goodness-of-fit statistic is reported to determine if the model provides a good fit for the data (p > 0.05) [28]. The strength of association was interpreted using the adjusted odds ratio (AOR) with 95% confidence Interval (CI). A p ≤ 0.05 was considered statistically significant.

COVID-19 Vaccine Acceptance and Demographic Characteristics
Among the 879 participants, 762 (86.8%) were willing to receive the COVID-19 vaccine, 52 (5.9%) refused, 64 (7.3%) were undecided whether to receive it or not, and 1 (0.1%) did not answer the question on whether they would take the vaccine or not (Fig. 1A). Of the 116 (13.2%) who said they would not accept a COVID-19 vaccine, 62 (53.4%) reported that the vaccine had not been studied well enough, 27 (23.3%) reported lack of trust of those developing and distributing the vaccine, 24 (20.7%) reported fear of potential side effects, and 3 (2.6%) did not answer the question related to why they would not take the vaccine (Fig. 1B). COVID-19 vaccine acceptance rates were shown to differ among the various demographic groups. Males (226/254, 88.9%), those aged 55 or older (95/100, 95%), and Lebanese (745/857, 86.9%) had the highest rates of acceptance ( Table 2). The multivariable logistic regression analysis showed that after adjusting for gender, age, religion, and education level, significant findings were seen in a couple of demographic factors (Table 3). Participants with a previous SARS-CoV-2 infection (OR: 0.47; 95% CI 0.30-0.75; p = 0.002) and those who did not know if they had a previous infection (OR: 0.24; 95% CI 0.10-0.60; p = 0.002) were less likely to accept the vaccine compared to those with no previous SARS-CoV-2 infection. No significant association was seen in the other demographic factors after adjustment.

Discussion
During early 2021, the majority of HCWs in Lebanon reported they would accept a COVID-19 vaccine (86.8%). Our finding of 86.8% is significantly higher than what was previously reported among Lebanese HCWs (26.8%) [29]. The major difference between both acceptance rates may be because our study collected data more recently (January 2021 to May 2021), compared to the previous study that collected data only in January 2021. Therefore, the acceptance of COVID-19 vaccines among Lebanese HCWs may have been higher in our study as evidence for the efficacy of the vaccines became more widely available over time [30]. Another possible reason for the major difference in acceptance rates may be due to the difference in methodologies between both studies-our study distributed the survey via email, WhatsApp message, or Short Message  [14,19,25,31,32]. While this is not a direct comparison as some of these countries were surveyed prior to the vaccine becoming available, some countries, such as the UAE (89.2%), have reported a similarly high acceptance rate as found in our study. Among those who refused COVID-19 vaccination, the main reason for their refusal was that the vaccine had not been tested well yet (54.9%). The rapid development of COVID-19 vaccines is thus manifesting as a major factor in vaccine hesitancy, as studies from the U.S. imply that the accelerated vaccine approval process played an important role in this regard [33]. Additionally, other reasons for vaccine refusal in our survey were attributed to lack of trust in those developing and distributing the vaccine as well as fear of potential side effects. Lack of trust is a global phenomenon as the amount of circulating misinformation about the SARS-CoV-2 virus has been a major factor in people losing confidence in governments and health care officials [34]. This offers an opportunity to address the important role of government officials and the Ministry of Public Health in increasing vaccine confidence by disseminating accurate information about the COVID-19 vaccine, whether through expert panels on the science and manufacturing of these vaccines, or the continued showcase of the incredibly abundant emerging safety data.
The vaccines approved and administered in Lebanon are currently the Pfizer-BioNTech, Oxford-AstraZeneca, Sputnik V, and Sinopharm vaccines [7]. Although these vaccines have been thoroughly tested, approved, and administered to hundreds of millions around the world, the high acceptance rate reported in HCWs in this study was greater than that of the general population, which was found in a previous crosssectional study conducted in Lebanon between November and December 2020 (21.4%) [22]. This may be because both    studies were conducted at different time points-the general population was surveyed before COVID-19 vaccines were introduced in Lebanon, while our study was conducted when vaccine administration began for HCWs. Additionally, HCWs may have a higher COVID-19 vaccine acceptance rate than the general population because they are likely to be more knowledgeable of the COVID-19 pandemic, given their direct exposure to COVID-19 cases. Studies have shown that the recommendation of governments and healthcare providers of the COVID-19 vaccination is a positive predictor of acceptance in patients [35]. The disparity in acceptance between HCWs and the general population offers an opportunity for our health care professionals to mobilize the population to encourage individuals to get the COVID-19 vaccine. This should be done through campaigns, media appearances, and active encouragement in clinics and hospital settings to boost receipt as much as possible. This suggests that the Lebanese MOPH could also work with the Lebanese HCWs to develop COVID-19 messaging and educational campaigns that cater to the general Lebanese population. One intervention that has worked well to help increase COVID-19 vaccine rates is the Inter-ministerial and Municipal Platform for Assessment Coordination and Tracking (IMPACT) national vaccination platform [36]. IMPACT generates online real-time data dashboards, supports assisted vaccine registration, allows users to report adverse events following vaccination, and includes a call center that assists with rescheduling appointments [36]. Overall, IMPACT has increased the transparency of the Lebanese MOPH's vaccination rollout and boosted public trust [36].
As stated earlier, a major pillar in vaccine hesitancy is related to reduced confidence in vaccine manufacturers, distributors, governments and international organizations. Our study found that a majority of Lebanese HCWs highly regard the Lebanese MOPH and the WHO as reliable sources of information in relation to COVID-19. Additionally, Lebanese HCWs reported confidence in health care providers (doctors, nurses, and pharmacists), which underscores the importance of spreading the correct scientific information by these authoritative bodies and successfully competing with widespread misinformation falsely spread on social media. Reported confidence and trust of HCWs in their peers also highlights the need for healthcare providers to have peerbased interventions (e.g., engaging in expert panels and conferences to learn about the evolving vaccine safety and effectiveness data), which may increase COVID-19 vaccine acceptance [37].
After adjusting our data for multiple demographic characteristics, no significant differences in vaccine acceptance were found according to age or gender of participants. This is in contrast to multiple other studies that found women HCWs to be less likely to accept the COVID-19 vaccine [14,26]. The fact that the largest number of health care professionals surveyed were nurses and considering that the Lebanese nurse force is mainly female predominant, this might offer a possible explanation [38]. Nurses, since the beginning of the COVID-19 pandemic, have been spearheading the COVID-19 response and are thus responsible for taking care of the sickest and critical patients. This could explain the high rates of vaccine approval among this demographic, who may fear the morbidity and mortality associated with the COVID-19 infection.
Similarly, after adjustment of multiple demographic factors, no significant findings concerning the impact of religion on willingness to take the vaccine were reported in our study. When comparing with other studies, no clear association between religion and vaccine hesitancy was seen, as some studies showed religion influencing vaccine acceptance, while other studies showed no significant effects [39][40][41][42]. Our finding that there was no significant association between chronic conditions and vaccine acceptance was similar to a study conducted in Singapore [43], yet different from a separate study conducted in Ethiopia [44]. The lack of significant association between chronic conditions and vaccine acceptance found in our study may be due to HCWs' low risk perception for chronic conditions as being a catalyst for increasing the risk of hospitalization and death. As for religion, given Lebanon's religious diversity among its population, it would be interesting to further investigate participants' religious views and their level of religiosity to understand this lack of association.
HCWs with a previous SARS-CoV-2 infection were found to be less likely to take the COVID-19 vaccine as compared with those who had not been infected. A possible explanation of this finding is a false perception of acquired natural immunity in these individuals prompting them to decline future vaccines. According to the Center for Disease Control and Prevention (CDC) in the U.S., current recommendations are for individuals to be vaccinated regardless of previous infection status, as we do not yet know the extent and duration of naturally produced immunity from COVID-19 [45]. This subgroup of Lebanese HCWs must thus be targeted by pro-vaccine campaigns, and health care officials must take the lead in correcting any misinformation

Strengths and Limitations
While our study included a large enough sample size of 879 HCWs, and we knew our target population included approximately 20,000 HCWs, we were unable to track the number of emails and messages (WhatsApp and SMS) that were received, returned, and/or went to spam. Therefore, we were unable to calculate the response rate. Also, given that we used a purposive sampling method and not a stratified random sample; our findings may not be generalizable to the whole Lebanese HCW population. Furthermore, our study examined the intent to vaccinate, which may not always translate into vaccine uptake [47]. Moreover, because our survey did not define "chronic conditions" and whether these conditions were related to COVID-19, participants may have interpreted this differently, which may have affected our results.
Given that the French language is one of the most commonly spoken languages in Lebanon and the survey was only provided in English or Arabic, participants who did not read and understand English or Arabic may have not participated in our study. Lastly, our findings may be influenced by a social desirability bias, as HCWs may respond to the survey questions in a manner that is viewed favorably by others.
However, the main strength of this study is that participants were from multiple hospitals throughout different areas of Lebanon, so it is representative in this regard. Also, to our knowledge, this is the first study in Lebanon that helps understand COVID-19 vaccine perception and acceptance among HCWs, as opposed to studies done on the general population.

Conclusion
Our study showed that 86.8% of the Lebanese HCWs would accept a COVID-19 vaccine. Refusal of vaccination was mainly due to the perception that COVID-19 vaccines have not been tested well. The surveyed HCWs showed great confidence in the MOPH and WHO, which must be key communication platforms in the COVID-19 vaccination campaign.