Vaccine hesitancy among healthcare workers in low- and middle-income countries during the COVID-19 pandemic: Results from facility surveys across six countries

PLOS ONE RESEARCH ARTICLE Vaccine hesitancy among healthcare workers in low- and middle-income countries during the COVID-19 pandemic: Results from facility surveys across six countries a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Baral P, Ahmed T, Amor Fernandez P, Peters MA, Drouard SHP, Muhoza P, et al. (2023) Vaccine hesitancy among healthcare workers in low- and middle-income countries during the COVID-19 pandemic: Results from facility surveys across six countries. PLoS ONE 18(7): e0288124. https://doi.org/10.1371/journal.pone.0288124 Editor: Suhad Daher-Nashif, Keele University School of Medicine, UNITED KINGDOM Received: July 18, 2022 Accepted: June 20, 2023 Published: July 7, 2023 Copyright: © 2023 Baral et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: Data cannot be shared publicly because of data access restrictions put in place by the countries’ Ministries of Health. The data used were collected during the peak of the COVID pandemic to help the countries respond to the ongoing crisis. Data access requests may be sent to the World Bank/GFF secretariat at . Funding: The study was funded by the Global Financing Facility for Women, Children and Prativa Baral ID1,2*, Tashrik Ahmed3, Pablo Amor Fernandez1, Michael A. Peters1, Salome Henriette Paulette Drouard1, Pierre Muhoza ID1, George Mwinnyaa2,3, Charles Mwansambo4, Charles Nzelu5, Mahamadi Tassembedo6, Md. Helal Uddin7, Chea Sanford Wesseh8, Mohamed Lamine Yansane9, Julie Ruel Bergeron3, AlainDesire Karibwami3, Tania Inmaculada Ortiz de Zuniga Lopez Chicheri3, Munirat Iyabode Ayoka Ogunlayi3, Isidore Sieleunou3, Tawab Hashemi3, Peter M. Hansen3, Gil Shapira1 1 The World Bank, United States of America, 2 Department of International Health, Johns Hopkins Bloomberg School of Public Health, United States of America, 3 Global Financing Facility for Women, Children, and Adolescents, United States of America, 4 Ministry of Health, Malawi, 5 Federal Ministry of Health, Nigeria, 6 Ministry of Health, Burkina Faso, 7 Directorate General of Health Services, Bangladesh, 8 Ministry of Health, Liberia, 9 Ministry of Health, Guinea * Abstract Background Vaccine hesitancy remains a critical barrier in mitigating the effects of the ongoing COVID19 pandemic. The willingness of health care workers (HCWs) to be vaccinated, and, in turn, recommend the COVID-19 vaccine for their patient population is an important strategy. This study aims to understand the uptake of COVID-19 vaccines and the reasoning for vaccine hesitancy among facility-based health care workers (HCWs) in LMICs. Methods We conducted nationally representative phone-based rapid-cycle surveys across facilities in six LMICs to better understand COVID-19 vaccine hesitancy. We gathered data on vaccine uptake among facility managers, their perceptions of vaccine uptake and hesitancy among the HCWs operating in their facilities, and their perception of vaccine hesitancy among the patient population served by the facility. Results 1,148 unique public health facilities participated in the study, with vaccines being almost universally offered to facility-based respondents across five out of six countries. Among facility respondents who have been offered the vaccine, more than 9 in 10 survey respondents had already been vaccinated at the time of data collection. Vaccine uptake among other HCWs at the facility was similarly high. Over 90% of facilities in Bangladesh, Liberia, Malawi, and Nigeria reported that all or most staff had already received the COVID-19 vaccine when the PLOS ONE | https://doi.org/10.1371/journal.pone.0288124 July 7, 2023 1 / 15 PLOS ONE COVID-19 vaccine hesitancy among healthcare workers in six low- and middle-income countries Adolescents (GFF). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. survey was conducted. Concerns about side effects predominantly drive vaccine hesitancy in both HCWs and the patient population. Competing interests: The authors have declared that no competing interests exist. Conclusion Our findings indicate that the opportunity to get vaccinated in participating public facilities is almost universal. We find vaccine hesitancy among facility-based HCWs, as reported by respondents, to be very low. This suggests that a potentially effective effort to increase vaccine uptake equitably would be to channel promotional activities through health facilities and HCWs.However, reasons for hesitancy, even if limited, are far from uniform across countries, highlighting the need for audience-specific messaging. Introduction Vaccination remains one of the most powerful, safe, and effective tools in reducing outbreaks of preventable infections and improving health outcomes worldwide, and yet, immunization programs are repeatedly confronted with various forms of hesitancy [1–3]. The phenomenon of vaccine hesitancy is defined as the “delay in acceptance or refusal of vaccines despite availability of vaccine services” [4]. According to the World Health Organization’s (WHO) SAGE Working Group on Vaccine Hesitancy, vaccine hesitancy is distributed across a complex continuum between full acceptance and outright refusal, rather than a binary construct [4]. While it is highly context-specific, and varies across time, place, and type of vaccine product, vaccine hesitancy remains a persistent and ongoing challenge globally. Well before the COVID-19 pandemic, the WHO declared in 2019 that vaccine hesitancy stands out as one of the top ten threats to global health [5]. Indeed, global trends suggest that immunization rates may stagnate due to waning vaccine confidence [6], likely contributing to the rise in vaccine-preventable diseases such as measles [7]. In low (LICs) and lower-middle-income countries (LMICs), immunization programs also face persistent barriers in accessibility to vaccines, in addition to vaccine hesitancy. In the context of COVID-19, the global rollout of highly effective vaccines has been plagued by the lack of supply in many countries as well as delays in acceptance or refusal of the vaccine products, stemming from complex and context-specific motivations [8]. In addition to increasing supply globally, individual and community-level reasoning for hesitancy must be identified and addressed, particularly among health care workers (HCWs). HCWs are at greater risk of infection and need to be protected to ensure a health system’s functionality, especially during outbreaks. They are also regularly in close contact with vulnerable populations and patients, where vaccination can act as an important layer of protection to prevent HCW-to-patient transmission. Indeed, increased vaccine coverage (...truncated)