Knowledge, attitude, and practices of front line health workers after receiving a COVID-19 vaccine: a cross-sectional study in Pakistan

Design

A cross-sectional study was conducted to assess the knowledge, attitude, and practices of FHW of Pakistan after getting the COVID-19 vaccine from April 15, 2021, to July 15, 2021. Because of the third wave of COVID-19 in Pakistan, it was not possible to perform the community-based survey; therefore, a semi-standardized electronic questionnaire was designed to collect the data using an online secure Google survey tool, and a shareable link was produced (https://docs.google.com/forms/d/1YCUf42WO3X2qS6hf36tw_6x6Ni5eAS4YZVn6W_L33ks/edit) and disseminated through multiple social media such as a personal social network, Facebook, and WhatsApp with mandatory email addresses to ensure one response per individual so that results may not be compromised. The survey includes an introduction that specified the purpose of the study. The data were collected anonymously, and email addresses were kept confidential. The biasness of the study with respect to participation was decreased by keeping the survey open for 3 months which provided ample time for people to participate in the survey.

Ethical declaration

The current study was conducted following the principles for human investigations (i.e., Helsinki Declaration) and has passed the ethical approval from the institutional review board of Akhtar Saeed Medical and Dental College (M-21/069/-Oral Pathology). All the respondents participated willingly in the survey. The respondents were assured that their information will be kept confidential.

Inclusion and exclusion criteria

The inclusion criteria of the study participants were being a Pakistani resident, FHW, and having internet access. The exclusion criteria included an incomplete survey.

Sample size

The sample size was calculated using the following equation:

$$n={\displaystyle \frac{z^{2}pq}{d^2}}$$

$n={\displaystyle \frac{{1.99}^2\times 5\times \left(1-0.5\right)}{{0.05}^2}}$

$n=396.01$where,

n = number of samples

z = 1.96 (95% confidence level)

p = prevalence estimate (50% or 0.5%) (Islam et al., 2021)

q = (1 2 p)

d = precision limit or proportion of sampling error (0.05).

As there is no earlier similar study on FHW concentrating on knowledge, attitudes, and practices after getting the COVID-19 vaccine in Pakistan, the best assumption (p) made for the present study would be 50%. A sample size of 396.01 participants was assessed, assuming a 10% non-response rate. Our sample size exceeded this estimate.

Questionnaire

A 30-item online self-administered questionnaire was made from earlier studies according to the objectives of the current study (Danabal et al., 2021; Islam et al., 2021). The Google form consists of four key focus areas, including socio-demographic data, knowledge about COVID vaccine, post-vaccination attitude, and practices along with informed consent. Each section consists of a range of options from multiple choices to forced-choice (yes/no) questions depending on the subject matter. All the questions were compulsory. In the first section, respondents were asked nine questions regarding their socio-demographic characteristics such as age and gender. The key independent variables were knowledge and attitude related to the COVID-19 vaccine. Knowledge of the COVID-19 vaccine was assessed using four items with three possible responses (i.e., Yes, No, and Don’t know). A sample item used to assess knowledge included: Vaccine is important to end the COVID-19 pandemic. A higher score on the scale showed higher knowledge of the COVID-19 vaccine. Attitude toward the COVID-19 vaccine was assessed using 10 items with five possible responses (i.e., Strongly disagree, Disagree, Neutral, Agree, and Strongly agree), which were later recoded to three responses (Disagree, Neutral, and Agree). A sample item used to assess attitudes included: Do you believe that the benefits of COVID-19 vaccination are greater in comparison to its risk? A higher score on the scale showed favorable attitudes toward COVID-19 vaccine. The dependent variable included in the study was practiced after getting the COVID-19 vaccine, which was assessed using six items with three possible responses (i.e., Yes, No, and Don’t know). A sample item used to assess practices included: Do you still follow COVID-19 basic prevention guidelines after getting vaccinated? A higher score on the scale showed favorable practices toward COVID-19 vaccine.

Participants

The target population of the current study was FHW, including physicians, dental surgeons, pharmacists, physiotherapists, laboratory technicians, nurses, hospital administrative staff, and undergraduate medical and allied health sciences students from all over Pakistan. A total of 635 responses were obtained.

Statistical analysis

The data cleaning, editing, and sorting were done on the Microsoft Excel version (2014). The data were then imported on SPSS version 20 (IBM Corp., Armonk, NY, USA) spreadsheet where the coding of data and analysis was done. The quantitative data are presented in the form of descriptive statistics as frequencies and percentages. First-order analyses such as the chi-square test and Fisher exact test were completed to check the association among socio-demographic characteristics (age and gender), attitude, and practices after COVID-19 vaccine.

To predict practices after getting the COVID-19 vaccine from socio-demographic and key independent variables (knowledge and attitude), a multivariate linear regression analysis was conducted. To test for multicollinearity, tolerance values and VIF ( ) values were considered which showed that multicollinearity was not a threat. A p-value <0.05 was considered statistically significant with a 95% confidence interval.

Demographic data

A total of 704 respondents from all over Pakistan participated in this study, out of which 69 were excluded because of an incomplete responses, and thus, the response rate for the study was 90.2%. Table 1 gives an outline of their socio-demographic characteristics. Most of the respondents (N = 296, 46.3%) were young (20–30 years), females (373, 58.7%), single (349, 55%), and completed a bachelor degree in dental surgery (289, 45.5%). The majority of the participants collected information about the COVID-19 vaccine via social media and television (241, 38%). The most frequently reported minor side effects were soreness at the injection site (N = 246, 39%), followed by body aches (N = 95, 15%) (Fig. 1).

Information regarding COVID-19

The results showed that, with more than half of the respondents (60%) stating that they were nervous before getting the COVID-19 vaccine, 31% of the respondents had been diagnosed previously with COVID-19 infection.

Data regarding COVID-19 vaccine knowledge

The participant’s responses regarding knowledge about the COVID-19 vaccine are summarized in Table 2. The most common reason for getting the COVID-19 vaccination was their concern to protect themselves and their community (53.4%). Intriguingly, 88.5% were aware that people can catch COVID-19 infection even if they are vaccinated.

Data regarding belief and attitude about COVID-19 vaccine

Table 3 shows the distribution of participants regarding the belief and attitudes of FHW after getting the COVID-19 vaccine. Of 635 respondents, 356 (56%) agreed that the newly developed COVID-19 vaccine is not safe as it is developed in an emergency. However, despite their concerns regarding the unseen effects of the COVID-19 vaccines (59.7%), most of the respondents still believed that it will not discourage them from getting vaccinated (84.5%). When it comes to trust in the measures taken by the Ministry of Health of Pakistan to ensure vaccine safety, only 59 (9.3%) did not have trust. The responses of participants are summarized in Table 3.

Practices after getting COVID-19 vaccine

The frequencies of practices among the respondents after getting the COVID-19 vaccine are presented in Table 4. It was observed that a large number of participants (95%) showed a positive attitude toward the preventive COVID-19 practices. The COVID-19 vaccine acceptance is related to the idea of recommending the vaccine to friends and family. Of note, a large majority of the respondents (93.9%) will recommend the COVID-19 vaccine to their friends and family. Females (N = 181, 58.4%) were more knowledgeable regarding the duration to build the immunity than males (N = 129, 41.6%), with a significant association between them (p = 0.034). There were significant differences in belief and attitude after getting the COVID-19 vaccine among both genders. It was observed that females (N = 112, 72.3%) were significantly more nervous before getting vaccinated than males (N = 43, 27.7%). Furthermore, female respondents were more likely to follow COVID-19 practices than males. It was observed that 50% of females wear a mask in comparison to males (40.4%) after getting the COVID-19 vaccine, which was found to be significantly associated (p = 0.046) (Table 5).

Out of 197 respondents who had a previous history of COVID-19 infection, it was observed that most of them were between 20 and 30 years old (N = 83, 42.1%), followed by 31–40 years old (N = 71, 36%), with a positive correlation among them (p = 0.036). When participants have inquired about the reason for getting vaccinated, it was seen that a majority of the respondents of 20–30 years old (N = 161, 47.5%) want to protect themselves and their community (p = 0.017). The level of nervousness before getting vaccinated was significantly associated (p = 0.000) among different age groups, i.e., decreasing with increasing age predominantly seen in 20–30 years (N = 71, 45.8%), followed by 31–40 years (N = 61, 39.4%), 41–50 years (N = 18, 11.6%), 51–60 years (N = 2, 1.3%), and above 60 years (N = 3, 1.9%) accordingly. Regarding practices among different age groups, it was found that all age groups followed the basic SOP of COVID-19 infection and individuals above 41 years old (100%) were more likely to wear a mask than those of younger age groups after their vaccination. The model predicting favorable attitudes after getting the COVID-19 vaccine was statistically significant, F (13, 621) = 4.609, p < 0.001, adj. R² = 0.069. The value of adjusted R² showed that approximately 7% of the variation in favorable attitudes after getting the COVID-19 vaccine was predicted by the independent variables of the study. The results showed that favorable attitudes after getting the COVID-19 vaccine increased with age by 0.37 but the change was statistically insignificant. Another finding of the study was that the favorable attitudes after getting the COVID-19 vaccine increased by 0.46 units in those respondents who were not currently practicing but it was statistically insignificant. The results further showed that with a one unit increase in knowledge of respondents for the COVID-19 vaccine, favorable attitudes after getting the COVID-19 vaccine increased by 0.34 units (B = 0.34, p < 0.001). Favorable attitude toward COVID-19 vaccine increased by 0.85 units in respondents who were nervous before getting COVID vaccine (B = 0.85, p < 0.01). The remaining variables included in the model were statistically insignificant (p > 0.05) (Table 6). Table 6 shows that the model predicting favorable practices after getting the COVID-19 vaccine was statistically significant, F (14, 620) = 10.10, p < 0.001, adj. R² = 0.167. The value of adjusted R² showed that 16.7% of the variation in favorable practices toward COVID-19 vaccine was predicted by the independent variables of the study. The results of multivariate regression analysis further showed that females were less likely to have favorable practices after getting the COVID-19 vaccine than males though the relationship was statistically insignificant (B = −0.24, p > 0.05). A significant finding of the study was that the favorable practices toward COVID-19 vaccine increased by 0.49 units in married respondents (B = 0.49, p < 0.01). Another significant finding of the study was that the favorable practices toward vaccines increased by 0.16 units with one unit increase in sources of information (B = 0.16, p < 0.05). This shows that respondents with multiple sources of information adopted favorable practices after getting the COVID-19 vaccine compared to those with fewer sources of information. The results also showed that those who had been previously infected with COVID-19 displayed poor practices toward the COVID-19 vaccine (B = −0.55, p < 0.01). Both key independent variables included in the study were statistically significant. The results showed that with a one unit increase in knowledge of respondents with respect to COVID-19 vaccine, favorable practices after getting the COVID-19 vaccine increased by 0.34 units (B = 0.34, p < 0.001). Furthermore, one unit increase in favorable attitudes after getting the COVID-19 vaccine increased favorable practices toward COVID-19 vaccine by 0.10 units (B = 0.10, p < 0.001).