Background: Awareness of the COVID vaccine and positive beliefs can help in the reduction of coronavirus morbidity and mortality. Aim: The study aimed to examine the effect of application of health belief model COVID vaccine acceptance among university employees in Namas City. Materials and Methods: quasi-experimental research design. The study was conducted in all faculties of Bisha University at Namas district in south KSA. A convenience sample of Saudi employees taking only one dose and refusal received vaccination against COVID at the University of Bisha, Al-Namas branch. The study was conducted from the beginning of February 2021 to the end of 2021 covering 6 months. Three tools were used to conduct this study: a self-administrated questionnaire first tool,about sociodemographic and COVID vaccine knowledge, second tool was HBM scale and third tool. Three tools questionnaire to assess design making toward vaccination against COVID-19 and what are barrier and hesitancy to receiving the COVID-19 vaccine after implementation educational program. Results: Most of the university employees acceptance of COVID vaccine and improved their knowledge and significantly improved HBM constructs compared with the scores before the program (P<0.001). Conclusion: After implementation of the nursing educational program about COVID vaccine for Saudi employees, knowledge improved significantly, and there were significant improvements in perceived severity, barriers, benefits, and the cues to action scores after the program compared with the scores before program (P≤0.001). Recommendations: Propagation of educational programs based on HBM on COVID vaccine to various age groups would help raise public awareness about COVID vaccine and change to positive beliefs for reduction coronavirus morbidity and mortality.
The coronavirus disease 2019 (COVID-19) pandemic caused a major public health crisis around the world and expected to continue to impose enormous burdens of morbidity and mortality 1, 2. The pandemic poses a significant threat to the public health system, including catastrophic economic consequences around the world furthermore there are currently no specific antiviral treatments for COVID-19 3, 4.
In the end of 2020, the US Food and Drug Administration announced a vaccine to COVID-19 by Pfizer-BioNTech 18. This authorization was quickly followed by authorizations to other vaccines by Moderna, AstraZeneca/Oxford and Jansen. Immediately after the first vaccine became available, mass vaccination campaigns against COVID-19 were initiated around the world 19.
Despite of the availability of safe and effective COVID-vaccines, some people in different parts of the world is not accepted to get vaccinated, mainly due to dilemma spread of false information and beliefs through social channel media among many people due to the large number of companies that produced the vaccine 5. Therefore, it is of important priorities to understand the motivators and barriers that influence the general public to vaccinate against COVID-19. Such understanding would help prepare intervention plans based on accessibility to the general public while targeting populations that show a tendency not to get vaccinated 20.
Numerous studies in many countries illustrated that the vaccine acceptance and demand are complex in nature and context-specific, varying across time, place, and perceived behavioral nature of the community 6, 7, 8. A study in China showed that some people delay and avoided COVID vaccination due to their misconception, efficacy, and trust in the vaccine 9. In Hong Kong, anxiety level and vaccine history were the main predictors towards vaccine acceptancy 10. Another study in the United States, reported that only 20% intend to decline the COVID-19 vaccine 11.
A study conducted in Saudi Arabia showed determinants of acceptance of COVID-19 vaccination reported that the Participants’ perceived risk and trust in the health system were found to be significant predictors towards the intention of the COVID-19 vaccine in the Kingdom 21. Furthermore, Health education in many studies different targeting socio demographic groups taken as a priority to increase flu vaccine awareness behavior in KSA, and elsewhere 22. In addition, recent studies showed that trust in the healthcare system and vaccine manufacturing is a crucial component of health education programs that target to promote lifesaving vaccines 12.
Health belief model may aim to increase perceived susceptibility to and perceived the seriousness of a health condition by providing education about the prevalence and incidence of disease, personal estimates of risk, and data concerning the results of sickness (e.g., medical, financial, and social consequences) 23. Interventions may also aim to alter the cost-benefit analysis of engaging in a health-promoting behavior (i.e., increasing perceived benefits and decreasing perceived barriers) by providing information about the efficacy of various behaviors positive 13.
1.1. Significance of the StudyThe COVID 19 pandemic poses a significant threat to the public health system including catastrophic economic consequences around the world. Saudi Arabia has been plagued with several pandemics, including the COVID-19 outbreak. As of the virus has rapidly spread in the Kingdom, causing a total of 341,495 laboratory-confirmed cases with 5144 deaths. COVID-19 vaccine is one of the most successful and cost-effective health interventions to prevent coronavirus. Also, recent studies showed that trust in the healthcare system and vaccine manufacturing is a crucial component of health education programs that target to promote life-saving vaccines. Regular assessment and surveillance of trust levels with a focus on deliberate initiatives to establish trust in immunization programs represent important steps to narrowing vaccine confidence gaps. The community nurse can provide health promotion & psychosocial services include assessment, health education, counseling & appropriate referral.
1.2. Aim of the StudyThe aim of the study was to examine the effect of application of belief on COVID vaccine acceptance among employee’s university in Namas city. The aim of this study was achieved through the following objectives:
1) To assess the level of university employee knowledge and health beliefs regarding COVID vaccine
2) To implement nursing educational program based on HBM for university employee.
3) To evaluate the effectiveness of the nursing educational program based on health belief model (HBM) on the acceptance of vaccination against COVID-19.
4) Identify the barrier and hesitancy to receiving the COVID-19 vaccine among employee participants after implementation program.
1.3. Research Questions1. Is the nursing educational program based on HBM will improve knowledge about COVID Vaccine among sample study?
2. Is the nursing educational program based on HBM will change health beliefs toward vaccination against COVID-19 among sample study?
3. Do employees after implementing the program receive vaccinations?
4. What are barrier and hesitancy to receiving the COVID-19 vaccine among employee participants after implementation program?
1.4. Subject and MethodsTechnical design:
Research Design:
Quasi-experimental research design (one group pre/post) was used in the current study.
1.5. SettingThe study was conducted in all faculties of Bisha University at Namas district. Faculties named Applied Medical Sciences faculty, faculty of Sciences and Arts, and Community faculty.
1.6. SubjectsThe subjects of the current study were Saudi administrative staff/security staff/drivers and cleaners in the aforementioned colleges working in Bisha university at Namas district in KSA.
1.7. Sample Size and Sample TechniqueA convenience sample of 105 employee was recruited to participate in this study with inclusion criteria Saudi nationality, not received or first dose received from COVID vaccine and agree to participate in the study. The sample size was determined according to the following equation: N = (Zα)2 × pq/d2, Sahai and Khurshid, 1996 24. The estimated sample sizes will be:
 |
Zα = the value of standard normal distribution for type I error probability for the sided test and equals 1.96.
p = 26%.
q = 1- p
d 2 = the accuracy of estimate = (0.05)2
1.8. Tools for Data CollectionThe following two tools were used for data collection through self-administrated questionnaire:
First tool: self-administrated questionnaire was developed by the researcher in Arabic language after reviewing the literature and experts' opinion; it comprised the following parts:
Part 1-Characteristics of participants:
Firstly, socio-demographic characteristics including age, gender, marital status, residence, educational level, and family income. Secondly, Health History of participants; it was used to assess any one of the participants suffering from chronic disease and diagnosed with Corona virus and received COVID vaccine.
Part 2- Assessment of Knowledge about COVID-19 vaccination: it was used as pre and posttest composed of 20 questions based on Saudi ministry of health guidelines booklet in 2021toward COVID vaccine 25 to assess knowledge level of university employees regarding Covid vaccine (five yes or no, and 15 multiple choice); importance of vaccination, action of vaccine, adverse effect of vaccination and how to deal with it. COVID 19 vaccine benefit, there is relation between COVID vaccine and infertility or any other diseases ...etc.
Scoring system of knowledge: a correct answer was scored "one" and the incorrect "zero". The knowledge score was calculated by adding the scores for the correct answers. The total score of each section was calculated by summation of the scores of its items. The total score for the knowledge of a participant was calculated by the addition of the total score of all sections. The mean and standard deviation was calculated.
Tool (2): Modified Health Belief Model Questionnaire: (Was adapted from Wayne, 2019). Designed to measure employee psychological readiness to take positive action regarding COVID 19 vaccination. It is including five subscales for health belief.
Subscale (1) perceived susceptibility: This refers to an employee subjective perception of the risk of acquiring COIV-19 from vaccination. It consisted of (3) items (i.e., My chance of getting COVID-19 in the next few months is high) ..etc.
Subscale (2) Perceived severity: refer to the negative consequences an employee associate with an event. This subscale consisted of (3) (i.e., The complications from contracting COVID-19 are serious) ..etc.
Subscale (3) perceived benefits: refer to the positive consequences that are caused by a specific action toward COVID vaccine. This subscale consisted of (2) items (i.e., Vaccination decreases my chances of getting COVID-19 or its complications) ..etc.
Subscale (4) perceived barrier: this refers to an employee feeling on the obstacles to performing recommended health action. These subscales consisted of (3) items (i.e., I am concerned about the efficacy of the COVID-19 vaccination). etc.
Subscale (5) cues of action the stimulus needed to trigger the decision-making process to accept a recommended health action. These subscales consisted of (2) items (i.e., I will only take the COVID-19 vaccine if I was given adequate information about it) ...etc.
Scoring system:
The scoring system: A five-point Likert scale to evaluate the statements was used. Positive statements were given a score of agree (2) and disagree (1). Scores of negative statements were inversed as follows: disagree (2) and agree (1). The mean and standard deviation was calculated.
Tool (3) The questionnaire was designed by the researchers to assess acceptance and hesitancy COVID vaccine after implementation education program based on HBM which include two question. first question (closed ended) "was Do you register yourself on the system and take the covid vaccination after attending the educational program" second question (open end question) was what the barrier and hesitancy about is don’t receive COVID vaccine.
The operational design includes preparatory phase, content validity, reliability, pilot study and field work.
A-Preparatory phase
It includes reviewing of literature, different studies and theoretical knowledge related to COVID 19 vaccine using books, articles, internet, periodicals and magazines.
B- Content validity:
To achieve the criteria of trust worthiness of the data collection tools in this study. Tools were tested and evaluated for content validity by three experts in community health nursing. They were from different academic categories, i.e., professor and assistant professor from faculty of Medicine in Bisha university. To ascertain relevance, clarity, applicability, and completeness of the tools. Based on expert’s comments and recommendations, minor modifications had been made such as rephrasing and rearrangements of some sentences.
Tool Reliability:
The reliability of the tools that was assessed through measuring their internal consistency by determining Cronbach alpha coefficient, proved to be high as indicated in the following table:
 |
Ethical considerations: Ethics approval obtained from the University of Bisha Ethics Committee (Ref No: UBCOM/H-06-BH-087(07/01). Therefore, The study sample was informed about the purpose and expected outcomes of the study and they was assured that the study is harmless, and their participation is voluntary, and they have the right to withdraw from the study at any time and without given any reason. They were assured also that anonymity and confidentiality were guaranteed
Pilot Study:
The pilot study was carried out in the beginning of January 2021, before data collection. It was conducted on 10 % of study subjects (10 cases) who were later excluded from the main study subjects to test and evaluate the clarity, feasibility, and applicability of the research tools and to estimate the time needed to collect data.
Field work:
Before conducting the study, permission was obtained from the administrative director for each faculty to carry out the study. The researchers met the employees, and the aim of the study was explained to them. Their informed verbal consent was secured before collecting data. The study was conducted through four phases: assessment, planning, implementation, and evaluation. These phases were carried out from the beginning of February 2021 to the end of July 2021. The previously mentioned setting visited by the researchers 3 days/week (Tuesday, Wednesday, and Thursday) from 10.00 a.m. to 1.00 p.m. The questionnaires put in Google form and distributed by what sup group. Each week completed from 15 to 20 questionnaires.
Assessment: After finalizing of the tools in pilot study, the researchers met the employees and filled out the questionnaire by google form in mobile to assess knowledge about COVID vaccine, and then the second tool was completed. The data obtained during this phase considered the basis for evaluation of educational program (pretest).
Planning and implementation phase: After identifying the needs of employees in the assessment phase, the researchers developed nursing educational program about COVID vaccine based on HBM constructs with simple Arabic language to be suitable for employees’ level of understanding. It emphasized the areas of important of Covid vaccine, action of COVID vaccine and indication. In addition, different types of COVID vaccine, adverse effect of COVID vaccine and how to deal with adverse effect. The employees’ participants in each faculty were divided into two groups, with each group including 15 employees. The program was applied through five sessions, and each session lasted 30–40 min. educational program hand-out was distributed to each employee. Teaching methods included small group discussions, open discussion, and brain storming. After the session, additional 5-10 min was offered for answering more questions.
Evaluation: Evaluation phase After implementation of the educational program, its effect was assessed by posttest evaluation. The evaluation was done immediately one time after the program using the same tools of pretest evaluation in addition asking the employees about design making toward vaccination against COVID-19 and what are barrier and hesitancy to receiving the COVID-19 vaccine.
Data analyzed with SPSS, version 18. Descriptive statistical analyses used, all qualitative variables described as numbers and percentages while quantitative variables as mean ± standard deviation (SD). The paired sample t-test used to compare mean scores before and after the intervention.
This study designed to examine the effect of application of belief on COVID vaccine acceptance among employee’s university in Namas city at south KSA.
Table 1 shows that the mean age in the sample were 37.86 ±9.23year, 81% of them were married and 58% of them were female. Regarding the educational level, the study illustrated that 62.8%% of the sample had bachelor education, 24.8% of the sample had intermediate education, and 8.6% was secondary. In this study, 56.3% were administrative employed and 21.9% of the subjects employed in information technology.
Table 2 demonstrate that 18.1% of the studied sample had chronic disease, 14.2% were diagnosed from corona virus and 71.5% of them do not receive covid vaccine and 28.5% of them received only first dose.
Table 3 illustrates a significant difference in all items of employee knowledge regarding COVID vaccine after program implementation compared to before implementation whereas (P value=0.00000).
Figure 1 reveals that the mean score of total knowledge before implementation is 35.54±11.15, while the mean score of total knowledge after implementation is 91.4±10.32. Thus, the figure shows the answer of the first research question related to improvement knowledge level about COVID vaccine.
Table 4 shows a significant difference between before and after implementation of health belief model in all components (P value =0.00000).
Figure 2 illustrates the improved total score of knowledge regarding COVID vaccine among employee under the study sample, after implementation educational program based on HBM observed positively change health beliefs about COVID vaccine in perceived susceptibility, perceived benefits, and cues to action. Table shows also reduce in negative belief in perceived severity, and perceived barrier. Thus, the figure shows the answer of the second research question related to changing health beliefs about COVID vaccine.
Figure 3, Demonstrates that acceptance status of employee under study sample 28.5% will complete second dosed of COVID vaccine, 31.5% of them definitely accepted vaccination against COVID. Despite the reported 27% of them hesitancy and 13% definitely refused COVID vaccination.
Table 5 shows that the most-reported barriers and hesitancy of COVID-19 vaccination were 47.6% fear of long-term genetic effects of some vaccine types and 26.2 % fear of (nano chips) implantation via vaccine followed by 19% fear of unknown adverse effects, thus this table answered on forth research question related to barrier and hesitancy to receiving the COVID-19 vaccine.
Vaccine refusal and hesitancy is a limiting step in global attempts to control the current pandemic with its adverse health and socioeconomic consequences. The current study designed to examine the effect of application of Health beliefs model on COVID vaccine acceptance among employee’s university in Namas city. We found that the majority of studied employee does not accept the vaccine, whereas a recent cross-sectional survey in the KSA found that the percentage of respondents who would definitely accept the vaccine to protect themselves from COVID-19 was more than quarter definitely yes and one third probably yes 14. In comparison with the respondents in the UK and US reported they would definitely not accept a COVID-19 vaccine less than one quarter 15. Our study revealed that the average age group is 37 years. In many recent studies in Ireland and the United Kingdom, 18-24 years old were more reluctant to receive the COVID-19 vaccine 16. Our study revealed that less than quarter of studied employees who were previously infected with COVID-19 which was similar to the findings of other studies in Saudi Arabia 17.
Regarding employee s knowledge on COVID vaccine, the present study revealed that all the employees had poor knowledge score about COVID vaccination before the program, which improved drastically after the program. This might be related to the effect of the nursing educational program on knowledge. These study findings supported the study research question number one that the nursing educational program based on HBM for university employee about COVID Vaccine will improve knowledge scores about COVID vaccination. These findings agreement with the study in Egypt who reported that the mean score of knowledge before the intervention was low regarding Pap smear and cervical cancer, whereas after the educational intervention, the level of knowledge improved significantly 16, 18. Moreover, the current study was similar with the study in Malisa who stated that the students in Malaysia had poor knowledge level of cervical cancer and its prevention 19. This might be related to needs of educational programs to improve cervical cancer knowledge and awareness of the public.
Regarding the mean scores of constructs of HBM, the present study found to be significant difference between before and after implementation of health belief model in all components. application of educational program improved positively change health beliefs about COVID vaccine in perceived susceptibility, perceived benefits, and cues to action. Therefore, reduce in negative health belief in perceived severity, and perceived barrier. Moreover, the nursing educational program might increase the awareness toward COVID vaccination. These study findings supported the study hypothesis number two that the nursing educational program based on HBM will change health beliefs positively toward COVID vaccination. Similar HBM outcomes were also found in a study performed in Japan, these findings suggested that the constructs of HBM could be used to explain vaccine uptake behaviour, as in previous studies demonstrating the capability of the HBM constructs in predicting behaviours related to influenza vaccination 12. While cues to action is an important element of HBM and they were found to be a significant driving force of vaccine acceptance, we found a remarkable pattern for COVID-19 vaccine. However, because of the lack of knowledge and too many manufacturers all comet once, it is more likely for potential vaccine recipients to doubt the legitimacy of less well-known manufacturers, which could intern lower their vaccine acceptance. Government should also proactively provide information about their selected vaccine manufacturers to break this barrier.
Notable, we clarified that a key component of HBM perceived susceptibility to Corona virus infection was not associated with COVID vaccination acceptance. These points could be illustrated by the majority of people belief in COVID-19 is perceived as a mild disease unless the infected person has chronic conditions. This guidelines of the direction of awareness and education for COVID-19 vaccine might have to be different from other vaccines in which prevention of infection is perceived as the main intention. Rather, perceived severity being a significant factor should be a focus for vaccine campaigns.
In our study, the most of employees accepted to receive COVID-19 vaccines after implementation program. This agreed with the study in US whose study showed that HCWs who are vaccinated against COVID-19 after giving information about COVID vaccine 26. The results agreed with other studies where the odds of acceptance of vaccination after lecture session based on HBM about COVID vaccine 10. From my point of view, the acceptance of vaccination by the participants resulted from expectation about vaccination obligatory that to facilitate travel, transportation, and back normal life.
Regarding barriers and hesitancy to receiving the COVID‐19 vaccine were fear of long‐term genetic effects of some vaccine types and fear of (nano chips) implantation via vaccine. This agrees with the study in Egypt whose study showed that reasons of not accepted vaccination against COVID among HCWs 26. The results agreed with other study other study in Egyptian medical student where the main vaccination barriers were insufficient information regarding the vaccine and its potential adverse effects 27. From my point of view, the various types of vaccines produced from most countries, and false announcement on social media network, was a major reason for people's reluctance to take vaccines.
According to the results and research questions of the current study, the nursing educational program regarding acceptance of COVID vaccine among university employees improved their knowledge and significantly improved HBM constructs compared with the scores before the program (P<0.001).
On the basis of the results of this study, the following recommendations are proposed:
1. Propagation of educational programs should be initiated to raise public awareness about COVID vaccine
2. Further research is needed on a wide scale to assess the barriers of undertaking negative beliefs about COVID vaccine
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| In article | View Article | ||
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Published with license by Science and Education Publishing, Copyright © 2021 Heba Alkotb Mohamed, Samar Mohamed Abdelkader and Abeer Husain Al-Shehri
This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit
https://creativecommons.org/licenses/by/4.0/
| [1] | Lazarus JV, Ratzan SC, Palayew A, Gostin LO, Larson HJ, Rabin K, Kimball S, El-Mohandes A. A global survey of potential acceptance of a COVID-19 vaccine. Nature medicine. 2020 Oct 20: 1-4. | ||
| In article | View Article | ||
| [2] | Al-Mohaithef M, Padhi BK. Determinants of COVID-19 vaccine acceptance in Saudi Arabia: a web-based national survey. Journal of multidisciplinary healthcare. 2020; 13: 1657. | ||
| In article | View Article PubMed | ||
| [3] | Wang J, Jing R, Lai X, Zhang H, Lyu Y, Knoll MD, Fang H. Acceptance of COVID-19 Vaccination during the COVID-19 Pandemic in China. Vaccines. 2020 Sep; 8(3): 482. | ||
| In article | View Article PubMed | ||
| [4] | Shekhar R, Sheikh AB, Upadhyay S, Singh M, Kottewar S, Mir H, Barrett E, Pal S. COVID-19 vaccine acceptance among health care workers in the United States. Vaccines. 2021 Feb; 9(2): 119. | ||
| In article | View Article PubMed | ||
| [5] | Nguyen, T., Henningsen, K.H., Brehaut, J.C., Hoe, E. and Wilson, K., 2011. Acceptance of a pandemic influenza vaccine: a systematic review of surveys of the general public. Infection and drug resistance, 4, p.197. | ||
| In article | View Article PubMed | ||
| [6] | Xiao X, Wong RM. Vaccine hesitancy and perceived behavioral control: A meta-analysis. Vaccine. 2020 Jul 14; 38(33): 5131-8. | ||
| In article | View Article PubMed | ||
| [7] | Larson HJ, Jarrett C, Eckersberger E, Smith DM, Paterson P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic review of published literature, 2007-2012. Vaccine. 2014 Apr 17; 32(19): 2150-9. | ||
| In article | View Article PubMed | ||
| [8] | Chan EY, Cheng CK, Tam GC, Huang Z, Lee PY. Willingness of future A/H7N9 influenza vaccine uptake: a cross-sectional study of Hong Kong community. Vaccine. 2015 Sep 11; 33(38): 4737-40. | ||
| In article | View Article PubMed | ||
| [9] | Quinn SC, Jamison AM, An J, Hancock GR, Freimuth VS. Measuring vaccine hesitancy, confidence, trust and flu vaccine uptake: Results of a national survey of White and African American adults. Vaccine. 2019 Feb 21; 37(9): 1168-73. | ||
| In article | View Article PubMed | ||
| [10] | Wong MC, Wong EL, Huang J, Cheung AW, Law K, Chong MK, Ng RW, Lai CK, Boon SS, Lau JT, Chen Z. Acceptance of the COVID-19 vaccine based on the health belief model: A population-based survey in Hong Kong. Vaccine. 2021 Feb 12; 39(7): 1148-56. | ||
| In article | View Article PubMed | ||
| [11] | Fathy EG, Elkarmlawy EM, Mohamed HE, Yousef FK. Effect of Educational Program on Prevention of Pesticides Hazards among Children Working in Agriculture. American Journal of Nursing Research. 2020 Feb 3; 8(2): 199-210. | ||
| In article | View Article | ||
| [12] | Mahmud I, Kabir R, Rahman MA, Alradie-Mohamed A, Vinnakota D, Al-Mohaimeed A. The health belief model predicts intention to receive the covid-19 vaccine in saudi arabia: Results from a cross-sectional survey. Vaccines. 2021 Aug; 9(8): 864. | ||
| In article | View Article PubMed | ||
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