To the best of our knowledge, this is the first Tunisian study that aimed at evaluating the acceptance of SARS-CoV-2 vaccines among all the categories of health professionals working in primary, secondary and tertiary care centers. It would provide a baseline reference for future evaluations. Our results would also serve for neighboring countries and other limited income countries in planning for their vaccination strategies.
Our study highlighted that between the 7th and the 21th of January 2021, 66.3% of Tunisian health professionals were thinking that they have high or very high risk of SARS-CoV-2 infection while 21.3% were thinking that they risk serious complications in case of infection. Acceptance rate of SARS-CoV-2 vaccine was 35.5% (95% CI: 31.3–39.7) whereas the prevalence of SARS-CoV-2 vaccine hesitancy was 51.9% (95% CI: 47.5–56.3). Working far from the capital (in the south or in the central of Tunisia) and concerns about the vaccines components predicted more hesitancy among participants. In contrast, the use of the national COVID-19 information website predicted less hesitancy among them.
Despite the high rates of risk perception, only 35.5% of healthcare professionals in our sample were readily willing to get the SARS-CoV-2 vaccine. This low rate of vaccine acceptance is far away from the herd immunity targets [6]. It joins that in USA (36%) [15] and in Qatar (33.8%) [16]. However, it is lower than those in France (76,9%) [29], Italy (67%) [14] and Greece (78.5%) [30] and higher than those in several Arab countries [16]. Among paramedical participants, this rate was of 20.8%. Low vaccination acceptance rates were found among non-physician healthcare workers in other countries [31]. Otherwise, the hesitancy rate (51.9%) revealed by the current study was higher than that reported after an online opinion survey conducted among the same target population between the 10th and the 20th of January 2021 (33.6%). Nonetheless, this opinion survey showed a higher refusal rate of 23.5% [32]. The used sampling method during this online opinion survey was not reported. However, repartition of participants from the different fields of activities was similar to that observed in our study [32].
As reported in previous studies [33], participants were mostly females. The trend of feminization in the Tunisian health sector may explain somewhat this female predominance [34]. Analyzing hesitancy among participants according to the sex showed that females were less willing than males to uptake the SARS-CoV-2 vaccine. This result is harmonious with several other studies [12]. The higher male acceptance of vaccine may be due to a greater propensity for risk taking [35]. This also could be related to concerns among females about higher risks of induced autoimmune diseases or fertility problems as it was spread on social media [36, 37].
Older respondents were significantly less hesitant to uptake the SARS-COV-2 vaccine. However, having a chronic condition or allergy did not seem to contribute to this hesitancy among them. A recent scoping review reported that individuals of older age are more likely to accept COVID-19 vaccines [12]. This was explained by a perception of greater vulnerability to SARS-CoV-2 infection but also by higher education and greater experience in healthcare [12]. Indeed, among our participants, those who were trainees were more likely to be hesitant than those who have graduated.
Having its professional activity far from the north of the country (where is located the capital) predicted more hesitancy among participants. In line with this result, lower vaccination rates among deprived groups were observed in several surveys [15, 38, 39]. More efforts should be provided in the Tunisian underserved regions, especially in the south, in order to overcome regional disparities in terms of vaccination against SARS-CoV-2.
Professionals from private sector were significantly less hesitant to get the SARS-CoV-2 vaccine. This joins the results of a study led in Hong Kong [40]. This may be explained by economic reasons. In fact, in private sector; sick leave in case of COVID-19 episode is not regularly paid in Tunisia.
More frequent contact with COVID-19 patients was associated with less hesitancy towards the SARS-CoV-2 vaccine among participants. Indeed, a realistic risk perception allows the implementation of voluntary preventive behaviors [33]. On another note, having been previously infected by SARS-CoV-2 predicted less hesitancy among participants. Divergent results were reported regarding the association between previous COVID-19 infection and willingness to receive a SARS-CoV-2 vaccine [41,42,43]. These divergent attitudes may be explained by the lack of knowledge about the duration of protective immunity after infection by this new virus [44].
Among participants, 81.7% reported lack of information about SARS-CoV-2 vaccines. Social media were the most used information source by them, which joins the results of an Egyptian study [45]. Lack of information and use of social media to be informed about SARS-CoV-2 vaccines were both significantly associated with more hesitancy towards these vaccines among participants. These results corroborate those of similar studies led in Egypt and Italia [11, 21] [14, 46]. Concerns about the vaccines components represented another predictor of SARS-CoV-2 vaccine hesitancy among participants. In fact, doubts regarding the SARS-CoV-2 vaccines safety among health professionals were reported in several countries such Italy [14], Democratic republic of Congo [39] and Egypt [45]. Differently, the use of the official national websites was significantly associated with less hesitancy rates among participants. Similar result was observed in Saudi Arabia [41]. Indeed, improved information on vaccines has been shown to increase vaccines’ acceptance [47].
Focusing on the vaccination campaign in Tunisia, we can note that although the launch of the online registration to get the vaccine since 15 January 2021 [25], the vaccination did not start before 13 March 2021. In fact, there were difficulties to obtain vaccines doses [48]. Health professionals represented the first priority group [26]. The concomitant communication plan included a first step of registration promotion during February 2021 with disinformation countering via mass media and social media. The second step began in March 2021. It aims to facilitate registration of people and to inform them about where and when they can beneficiate from the vaccine [26]. After one year of the onset of the vaccination campaign, proportion of vaccinated health professionals is still unavailable [25, 26, 49]. In addition, the incidence of COVID-19 among health professionals does not figure on the periodic national reports [25, 26, 49]. As of 7 March 2022, four reports were published (since September 2021) about the recorded side effects among the vaccinated people [50]. However, the content of these reports was not disseminated through the official website of the ministry of health [26] or the national vaccination portal [25].
SARS-CoV-2 vaccine scarcity in Tunisia and poor resources [51] should not discourage policy makers to implement an effective information campaign. Involving health professionals, especially Public Health specialists, in this campaign would increase confidence in the vaccines, as they are experts in prevention methods. Involving partners from the other sectors such as anthropologists, artists and national leaders is also recommended. Sharing updated information with health professionals during periodic sessions would encourage hesitant ones to uptake the vaccine. Especially, females, the youngest ones, paramedical professionals and those in the underserved regions. The content of these sessions should focus on the severity of COVID-19 episodes and the impact of adherence to self-protective behaviors [52]. To increase confidence in the vaccines, the broadcast messages should report the development methods and the protection mechanisms of the SARS-CoV2 vaccines. Organizing vaccination sessions in the occupational health centers would encourage these groups to uptake the vaccine. Facebook represent another way for disseminating valid messages and tackling misinformation about the vaccines, especially that it represents the most famous social media platform in Tunisia [16]. Engaging health care professionals in social media to counter the vaccines’ related misinformation would improve the vaccine acceptance among the other health professionals and the general population as well. In fact, the general population considers them trustworthy.
More solidarity at the international level is required for a global COVID-19 vaccine equity. Otherwise, we risk the emergence and the spread of new variants of the SARS-CoV-2 which could threaten vaccinated and not vaccinated people worldwide.
Results of the current study should be interpreted with taking into account some limitations. Firstly, the cross sectional nature of the study did not allow to report causal relationships but only statistical associations. Besides, random sampling was not possible as no lists of national or regional health professionals were available. However, the required sample size was reached. Moreover, although that Public Health professionals were not represented in our sample because of their reduced number in Tunisia, the main categories of the health professionals were represented. Finally, attitudes and perceptions were self-reported by participants, which might lead to a social desirability bias. Nonetheless, data were collected anonymously and participation was voluntary.