Attitude of health professionals towards COVID-19 vaccination and associated factors among health professionals, Western Ethiopia: A cross-sectional survey.

INTRODUCTION: Even though people of the world were eagerly waiting for the hope of vaccine development, vaccine hesitancy is becoming the top concern in both developed and developing countries. However, there is no adequate evidence regarding the attitude and perception of health professionals towards the COVID 19 vaccine in resource-limited settings like Ethiopia. The aim of this study was to assess health professionals' attitudes and perceptions towards COVID 19 vaccine in Western Ethiopia.
METHODS: An institution-based cross-sectional study was conducted among health care workers found in Nekemte town from April 14-21, 2021. A total of 439 health professionals present on duty during the study period was included in the study. The data were collected by using self-administered questionnaire. Epidata version 3.2 was used for data entry, and STATA version 14 was used for data analysis. The binary logistic regression model was employed to determine factors associated with the attitude towards COVID-19 vaccination. Adjusted Odds Ratio (AOR) with 95% confidence intervals was computed and statistical significance was declared at a 5% level (p-value < 0.05). RESULT: A total of 431 health professionals participated in the study yielding a response rate of 98.1%. The results indicated that 51.28% (95%CI: 45.12%, 57.34%) of health professionals had a favorable attitude towards COVID-19 vaccination. Having good knowledge about the COVID-19 vaccine (AOR = 0.38, 95%CI: 0.22, 0.64, P-value <0.001) was negatively associated with unfavorable attitude towards COVID-19 vaccine, whereas age less than 30 years (AOR = 2.14, 95%CI:1.25,3.67, P-value <0.001), working in a private clinic (AOR = 7.77, 95% CI: 2.19, 27.58, P-value <0.001) and health center (AOR = 2.45, 95%CI: 1.01, 5.92, P-value = 0.045) were positively associated with unfavorable attitude towards COVID-19 vaccine. CONCLUSION AND RECOMMENDATION: In general, the attitude and perception of health care professionals toward the COVID-19 vaccine in the study area were unsatisfactory. Knowledge about the COVID-19 vaccine, age of health care workers, and place of work are the factors which affects attitude towards COVID-19 vaccine. Thus, we recommend the media outlets and concerned bodies to work to develop trust among the public by disseminating accurate and consistent information about the vaccine.

Introduction

Starting from the day it was declared a pandemic, COVID-19 remains the worst Global public health challenge. According to the worldometer report, COVID-19 affects about 220 countries and territories. More than 350 million cases, and 5.6 million deaths happened due to COVID-19 as of January 24, 2022 [1,2]. The pandemic brought the double burden in developing countries already overwhelmed by the health care system challenges [3].

Given that sub-Saharan Africans are not the highest shareholder by cases and death during the early phase [4], the direct effect of COVID-19 and the indirect effect of its mitigation, disrupted the health care services [5]. The serious preventive measures (movement restriction, physical distancing, lockdowns, hand washing and sanitizing) were practiced [6]. However, the counter effect of some mitigation brought significant change in health care settings especially by task shifting and task sharing. Its effect on the economy is also evident. Though these mitigation procedures played a paramount role in averting the burden of COVID19, the whole world was hoping for vaccine development [7].

A few COVID-19 vaccines that are being used globally or locally [7]. As of June 10, 2021, from 287 candidate vaccines, 102 are in the clinical phase, 185 are in the pre-clinical phase [8]. From these, WHO has listed the Pfizer/BioNTech, Astrazeneca-SK Bio, Serum Institute of India, Janssen and Moderna vaccines for emergency use [6,7]. Believing Health Care Workers (HCWs) are explicitly exposed to increased risk of infection through direct contact with patients, they should be prioritized for vaccination [9].

The willingness of the general population to accept the vaccine ahead of COVID-19 vaccine development was relatively promising compared to today’s reality [10-12]. Even though people of the world were eagerly waiting for the vaccine development, vaccine hesitancy is becoming the top concern in both developed and developing countries [11,13-17]. For instance, the vaccine acceptance is 21% in Egypt [18], 54.6% in China[19], and 57.6% of the adult population in the USA [20] intended to be vaccinated. Studies conducted in different regions of Ethiopia reported willingness to take COVID-19 vaccine were 46.1% in Southern Ethiopia [21],39.7 in Addis Ababa [22], and 48.6% in Southwestern Ethiopia [23]. The most common reason mentioned for hesitancy were concerns about the safety of a vaccine and wide-ranging lack of confidence, worries about the efficiency of the vaccine[17,18,24]

Several studies indicate that healthcare professionals (HCPs) play a paramount role and can significantly affect the general public’s decisions to receive the COVID- 19 vaccine [25,26]. In Ethiopia, there have been 169,640 confirmed cases of COVID-19, with 9651 deaths till May 30, 2021 [1]. The Ethiopian government and the Ethiopian Ministry of health exert great efforts to provide the COVID-19 vaccines and sort the vaccination as a priority for healthcare workers (HCWs) and older people, especially people with chronic diseases history [27]. To overcome the expected upcoming challenge of vaccination hesitancy, we have to measure and know the exact reasons. However, there is no adequate evidence regarding the attitude and perception of health professionals towards the COVID-19 vaccine in resource-limited settings like Ethiopia. Hence, this study aimed to assess health professionals’ attitudes and perceptions towards COVID 19 vaccine in West Ethiopia.

Methods

Study area and period

This study was conducted in health institutions located in Nekemte town. Nekemte is the capital city of East Wollega Zone, and it is located 330 KM from Addis Ababa, the capital city of Ethiopia. The study was conducted from April 15–21, 2021. Data from Nekemte Town Health Office showed that the town has one teaching referral hospital owned by Wollega University, one specialized hospital administered under Oromia Regional Health Bureau, two health centers (Nekemte and Cheleleki Health center), and more than fifteen medium and above private clinics, and more than 800 health professionals are found in Nekemte town.

Study design

An Institutional based cross-sectional study design was employed.

Population, sample size and sampling techniques

All health professionals working in private and public health institutions of Nekemte town were a source population. Health professionals who were not on duty due to different reasons were excluded from the study. All health professionals on duty during data collection and willing to participate in the study were selected.

The sample size was determined by single population proportion with the following assumptions: Since this study was the first of its type in Ethiopia, p = 50% was taken, with a 5% margin of error and a 95% confidence level. Accordingly, the calculated sample size was 384, and after adding a 15% allowance for a non-response rate, the final sample size was 442 health professionals.

All health institutions found in Nekemte town were included in the study. There are two public hospitals in Nekemte town, two health centers, and 15 medium clinics. Then the sample size was proportionally allocated to hospitals, health centers and private clinics. Around 710 health professionals are working in two hospitals, 50 in two health centers and 60 health professionals in all private clinics. For hospitals, we have used the identification number of the health professionals, and the identification number was used as a sampling frame. Then computer-generated simple random sampling technique was used to select the sample. Health professionals who were not on duty during the study period were excluded from the sampling frame. For health centers and private clinics, all health professionals who were available during the study period were included in the study. Furthermore, health professionals working in more than one health facility were considered only in a single health facility to prevent any distortion of information.

Variables

The attitude of health professionals towards the COVID-19 vaccine was the dependent variable of this study. For attitude questions, the likert-scale method with a five points scale (strongly agree, agree, neutral, disagree, strongly disagree) responses were used to allow the study participants to express how much they agree or disagree with a particular question. Ten items were used to assess the attitude of health professionals towards COVID-19 vaccine. Participants’ response was from 10 to 50. Higher scores denoted a “favorable attitude” towards COVID-19 vaccine. “Favorable attitude” was when the scoring was ≥ mean or 25 (50% and above) out of 50 items and < 25 (<50%) was rated as “unfavorable attitude”.

Socio-demographic variables such as (age, sex, marital status, educational level, educational background, religion), medical history (chronic medical disease and previously infected with COVID-19), knowledge towards COVID-19 vaccine, and perception towards COVID-19 vaccine) were independent variables of this study.

For knowledge related items, the questions contained the category of (“Yes”/“No”). A correct answer was assigned “1” point and an incorrect answer was assigned “0” points. The total score ranged from 0 to 5. “Good knowledge” was when the scoring was ≥2.5 (50% and above) out of 5 items and score below 2.5 indicated “poor knowledge” on COVID-19 vaccine.

Finally, the perception of participants towards COVID-19 vaccine was assessed by using five items with "Yes"/No" category. The total score ranged from 0 to 5. Respondents who scored greater than or equal to the mean score (≥ 2.5 or ≥ 50%) were grouped to have "good perception" and participants who scored less than the mean score (<2.5 or <50%) were grouped to have "poor perception" towards COVID-19 vaccine (S3 File).

Data collection techniques and data quality assurance

A questionnaire was developed by reviewing previously published papers [28,29], and adapted to local context. The tool was designed and distributed to respondents in English language since the participants could read, write, and understand the language. The questionnaires comprised socio-demographic data, medical history, knowledge, attitude, and perception towards the COVID-19 vaccine. The data was collected by using self-administered questionnaires. The questionnaire was given to all health professionals on duty and returned to data collectors after filling it. Cronbach’s alpha was used to assess the reliability of the tool, and the value was 0.78 (value more than 0.7 to 0.95 is acceptable) [30].

To ensure its quality, the questionnaire was pre-tested on 5% of participants. Then possible amendments were done based on the findings. The discussion was held between investigators and data collectors, based on the pre-test result, and accordingly, some amendments were made. The data collectors gave the one-day training about the tool and data collection procedure. Data were checked daily for completeness, accuracy, clarity, and consistency by the supervisors and principal investigator. Any error or ambiguity, and incompleteness were corrected accordingly.

Data management and analysis

Epidata version 3.0 was used for data entry [31], and exported to STATA version 14.0 for further analysis [32]. Descriptive statistics, like frequencies, percentages, mean and standard deviation were computed. Before analysis, data were cleaned and edited by using simple frequencies and cross-tabulation. Re-categorization of categorical variables and categorization of continuous variables was done. The assumption of the logistic regression model was checked before fitting to the model. The binary logistic regression model was fitted to determine factors associated with attitude towards COVID-19 vaccine. The multivariable logistic regression analysis included factors associated with the outcome variable at 20% (p-value ≤0.20) significant level in the bivariable logistic regression analysis. Then crude and adjusted odds ratio and their corresponding 95% confidence intervals were presented in the final multivariable logistic regression table. Finally, AOR with 95% confidence intervals was computed and statistical significance was declared when it was significant at a 5% level (p-value < 0.05). Correlation matrices checked multicollinearity (association between explanatory variables), and the model goodness of fit test was checked by Hosmer and Lemeshow test.

Ethical considerations

The study was approved, and ethical clearance letters were obtained from Wollega University, Institute of Health Science Research Ethics review board (Min. No. 07/2021). After approval, a permission letter was obtained from the administrative body of health facilities to respective clinics. Verbal consent was obtained from study participants, and the purpose of this study was stated to all participants. Everybody participated voluntarily in this study.

Results

Socio demographic characteristics of the health professionals

Four hundred thirty-one health professionals were filled the questionnaire and yielded a response rate of 98.1%. Two hundred sixty eight (62.28%) of participants were male. Regarding the age of the health professionals, nearly two-thirds of them, 274 (63.57%), belong to less than 30 years old age group. More than half 253(58.07%) of the participants were protestant religion followers. Greater than three fourth of the health professionals who participated in this study were from hospital institutions 350 (81.21%) (Table 1).

Table 1

Socio demographic characteristics of the health professionals in Nekemte city, Western Ethiopia, 2021.

Variables	Option	Frequency	Percent
Age	<30years old	274	63.57
	> = 30years old	157	36.43
Sex	Male	268	62.18
	Female	163	37.82
Marital status	Never married	176	40.84
	Married	243	56.38
	Separated	8	1.86
	Others	4	0.93
Religion	Muslim	73	16.94
	Protestant	253	58.70
	Catholic	10	2.32
	Orthodox	71	16.47
	Others	24	5.57
Institution	Hospitals	350	81.21
	Health center	34	7.89
	Private	47	10.90
Education level	Diploma	38	8.82
	First degree	362	83.99
	Masters	24	5.57
	Doctors	2	0.46
	Specialty degree	5	1.16
Back ground	Nurses	186	43.16
	Midwifery	56	12.99
	Pharmacy	32	7.42
	Medical practitioner	47	10.90
	Public health	41	9.51
	Anesthetists	19	4.41
	MLS	36	8.35
	Psychiatrics	6	1.39
	others	8	1.86

Medical disorder related characteristics of the health professionals

Thirty-three healthcare workers have a history of taking vaccination in their lives (7.66%). Nearly one fifth of the health care workers in this study had chronic medical diseases 19 (4.41%). Participants’ most commonly reported chronic disease was hypertension 6 (46.15%). Greater than half of the participants were vaccinated against coronavirus 240 (55.68%).

The attitude of the health professionals towards COVID-19 vaccine

Almost half 210 (48.72%) of the participants have poor attitude toward COVID-19 vaccination. One-third of the participants strongly agreed that COVID-19 could not be controlled without vaccination. Moreover, nearly one-third of participants agreed that mass vaccination against COVID-19 helps overcome the pandemic (Table 2). Regarding the effectiveness of the newly discovered COVID-19 vaccination, less than a quarter of the participants strongly disagreed with 63 (14.62%) (Fig 1).

Table 2

Attitude of the health care workers towards COVID-19 vaccine in Nekemte health facilities, Western Ethiopia.

Variables	Option	Frequency	Percent
The vaccine that is currently given in Ethiopia is the actual one that those innovative countries are taking	Strongly disagree	114	26.45
	Disagree	132	30.63
	Neutral	81	18.79
	Agree	79	18.33
	Strongly agree	25	5.80
If one person takes COVID-19 vaccination, it has a great contribution for other people	Strongly disagree	65	15.08
	Disagree	86	19.95
	Neutral	53	12.30
	Agree	155	35.96
	Strongly agree	72	16.71
I will take the vaccine if I get it without hesitation	Strongly disagree	61	14.15
	Disagree	183	42.46
	Neutral	51	11.83
	Agree	86	19.95
	Strongly agree	50	11.60
I encourage my family and others to take the vaccination	Strongly disagree	58	13.46
	Disagree	135	31.32
	Neutral	61	14.15
	Agree	127	29.47
	Strongly agree	50	11.60
COVID-19 cannot be controlled without vaccination	Strongly disagree	85	19.72
	Disagree	136	31.55
	Neutral	65	15.08
	Agree	111	25.75
	Strongly agree	34	34
COVID-19 vaccine is fairly distributed for all	Strongly disagree	67	15.55
	Disagree	122	28.31
	Neutral	84	19.49
	Agree	99	22.97
	Strongly agree	59	13.69
Mass vaccination can overcome the epidemic attack of the COVID-19	Strongly disagree	53	12.30
	Disagree	90	20.88
	Neutral	77	17.87
	Agree	138	32.02
	Strongly agree	73	16.94
The best prevention method is to take vaccine against COVID-19	Strongly disagree	54	12.53
	Disagree	91	21.11
	Neutral	92	21.35
	Agree	134	31.09
	Strongly agree	60	13.92
The COVID-19 vaccine is not tested adequately for its effectiveness	Strongly disagree	28	6.50
	Disagree	73	16.94
	Neutral	67	15.55
	Agree	129	29.93
	Strongly agree	134	31.09
After vaccinated against COVID-19 other precaution can be avoided	Strongly disagree	89	20.65
	Disagree	131	30.39
	Neutral	62	14.39
	Agree	66	15.31
	Strongly agree	83	19.26
The overall attitude towards COVID-19 vaccine	Favorable	221	51.28
	Unfavorable	210	48.72

Fig 1

Attitude of the health professionals regarding effectiveness of the Corona virus vaccine, 2021.

Health care workers perception towards COVID-19 vaccine

The distributions of each perception item about the COVID-19 vaccine are presented in Table 3. Concerning the question “Do you think the COVID-19 vaccine is effective”? Nearly one-third of them thought the vaccine against COVID-19 was effective. More than half of the participants responded unsure for the question “Do you think COVID-19 will be controlled only by preventive measures without vaccination”? (Table 3).

Table 3

Perception the health care professionals towards COVID-19 vaccine.

Variables	Option	Frequency	Percent
Have you ever been infected with COVID-19	Yes	95	22.04
	No	169	39.21
	I don’t know	167	38.75
Do you think that the COVID-19 vaccine is effective?	Yes	131	30.39
	No	34	7.89
	I don’t know	266	61.72
Do you think that COVID-19 vaccine is mandatory for health care workers?	Yes	262	60.79
	No	24	5.56
	I don’t know	145	33.64
Do you think COVID-19 will be controlled only by preventive measures without vaccination?	Yes	85	19.72
	No	102	23.67
	I don’t know	244	56.61
Do you think that various COVID-19 vaccines have been discovered?	Yes	142	32.95
	No	46	10.67
	I don’t know	243	56.38
Do you think that the COVID-19 vaccine will be affordable and accessible by the common person!	Yes	59	13.69
	No	145	33.64
	I don’t know	227	52.67

Almost half of the participants accept that the newly developed COVID-19 vaccine has side effect 209 (48.49%) (Fig 2).

Fig 2

Perception the health care workers regarding Corona virus vaccine’s side effect, 2021.

Factors associated with attitude of health professionals towards COVID-19 vaccine

In multivariable logistic regression, variables like age, sex, institution types, having chronic diseases and allergic reaction to previous medication have shown significant association with the outcome of interest. From those variables, two of them showed significant association with the attitude of health professionals toward a vaccine against COVID-19. The odd of developing poor attitude toward COVID-19 vaccine was 2.14 times higher among health professionals aged < 30 years than their counterparts (AOR = 2.14, 95%CI: 1.25, 3.67). The likelihood of having a poor attitude toward the COVID-19 vaccine was 2.45 times higher among health professionals working at health centers than those working at hospitals AOR = 2.45(95%CI 1.01,5.92). Similarly, the odds of having a poor attitude towards the COVID-19 vaccine was 7.77 times higher among health professionals working at private clinics and hospitals AOR = 7.77(95% CI 2.19,27.58). Moreover, the proportion of health professionals with unfavorable attitudes was 62% lower among professionals who have good knowledge of COVID-19 vaccination than their counterparts AOR = 0.38(95%CI: 0.22, 0.64) (Table 4).

Table 4

Multivariable analysis of factors associated with attitude towards COVID-19 vaccine among health professionals in Nekemte city, Western Ethiopia.

Characteristics		Attitude		COR(95%CI)	AOR(95%CI)	P-value
		Poor	Good
Age	<30	149	125	1.87(1.25,2.79)	2.14(1.25,3.67)	<0.01*
	> = 30	61	96	Ref
Sex	Male	125	143	Ref
	Female	85	78	0.80 (0.54,1.18)	0.93(0.54, 1.59)	0.795
Institution	Hospital	195	155	Ref
	Health center	10	24	3.01(1.40, 6.50)	2.45(1.01,5.92)	0.045*
	Private clinic	5	42	10.56 (4.0,27.35)	7.77(2.19,27.58)	<0.01*
Chronic diseases	Yes	9	10	Ref
	No	201	211	0.94(0.37,2.37)	0.76(0.25,2.29)	0.630
History of allergic reaction to previous medication	Yes	21	20	Ref
	No	189	201	1.11(0.58,2.12)	1.04(0.46,2.33)	0.914
Knowledge about COVID-19 vaccination	Poor knowledge	44	86	Ref
	Good knowledge	139	163	0.30(0.18,0.49)	0.38(0.22,0.64)	<0.01*

Discussion

Though the vaccine development against COVID-19 was promising for the world population, vaccine hesitancy has become a global challenge to the successful uptake of the vaccine [11,13-17]. Literature shows that vaccine safety and efficacy are among the worries of the people and the reasons for vaccine hesitancy [17,18,24]. Health care professionals are at a particular concern to be vaccinated to influence the general population for vaccination positively. There was a dearth of information about the attitude and perception of health professionals toward COVID-19 vaccination and its associated factor in Ethiopia, particularly in the study area. Therefore, this study was intended to determine the attitude of health professionals toward COVID-19 vaccination and its associated factors in Nekemte town.

Accordingly, 31.55% of the study participants had agreed to take the vaccine without hesitation if available in the present study. This is lower than the study findings from Southwestern Ethiopia (48.4%) [23], Eastern Ethiopia (61.4%) [33], Bangladesh (58.6%) [34], Canada (72.40) [35]. The possible explanation for this might be the variation in trust and reliability of the source of information about COVID-19 vaccine. Moreover, 41.07% of the study subjects in the present study have also agreed on encouraging families and others to take the vaccine while 65.5% of participants in Bangladesh agreed to do so. Furthermore, 59.75% of this study’s health professionals agreed that COVID-19 would not be controlled without vaccination. This echoes the finding from Bangladesh (63.4%) [34]. In addition, nearly half of the study participants in the current study have agreed on mass vaccination to overcome the pandemic. This is also congruent with study done in Libya [36]. Comparable to the study finding from Saudi Arabia (37%) [37], only one-third of participants agreed on the vaccine’s effectiveness in the present study. This depicts that there is still a need to provide reliable and accurate information about the vaccine’s effectiveness against COVID-19 to health care professionals and the public.

The current study revealed that half of the health care professionals who participated in this study have a favorable attitude toward COVID-19 vaccination. This is lower than the study done in Bangladesh reported that 78% of the general population had a favorable attitude [34]. However, it is higher than the online survey which was done in Ethiopia that reported 24.2% of the general population had a favorable attitude toward COVID-19 vaccination [38]. The possible reason for the observed discrepancy might be due to the relative information difference among the population of interest. Furthermore, it might be due to health care professionals being at higher risk of infection with the virus that might result in a favorable attitude toward vaccination to minimize the risk of infection. This implies a need to assure the vaccine’s effectiveness, safety, and efficacy to enhance its uptake by health professionals and the general public. Health professionals are the counselor and advocators of the general population that their decision to receive the vaccine can greatly influence the uptake by the general population.

The factors affecting health care professionals’ attitude toward COVID-19 vaccination were knowledge towards COVID-19 vaccination, age of respondents, and type of health facility. Accordingly, the proportion of health professionals who have unfavorable attitudes was 62% lower among professionals with good knowledge of COVID-19 vaccination than their counterparts. This might be because knowing the importance of the COVID-19 vaccine can positively influence someone to have a positive attitude toward it. Moreover, the odds of having unfavorable attitudes were much higher among health professionals working in private clinics and health centers than those in hospitals. This variation might be due to the relative number of client flow to the health center and private clinic being much lower than the hospital and, hence the professionals consider themselves at lower risk of exposure and infection to COVID-19. In addition, almost all COVID-19 patients have been admitted to hospitals than private clinics or health centers. Therefore, professionals working at health centers and private clinics for known and obvious reasons consider themselves to have a lower risk of infection with COVID-19. As a result, they might have an unfavorable attitude toward the COVID-19 vaccine than professionals working in the hospital setting.

In this study, age of HCWs were significantly associated with attitude towards COVID-19 vaccine, in which health professionals aged less than 30 years had negative attitude towards the vaccine. This is in line with study conducted in North Ethiopia which reported higher age positively associated with positive attitude towards COVID-19 vaccine [39]. This might be due to the fact that, as age increase, the probability of developing comorbidity increase, and the chance of infecting with COVID-19 also high. Thus the HCWs intention to receive the vaccine would be high.

Limitation of the study

The study did not provide qualitative perspectives on the attitude and perception of health professionals towards the COVID-19 vaccine and its associated factors, which, if available, could underpin the quantitative findings. Moreover, since it is a cross-sectional study, it did not address the cause and effect relationship between the factors and the outcome variables.

Conclusion

In general, the attitude and perception of health care professionals toward the COVID-19 vaccine in the study area were unsatisfactory. Having poor knowledge about the COVID-19 vaccine, young age group, working in private clinics and health centers are the independent determinants of unfavorable attitudes towards the COVID-19 vaccine. Therefore, there is still a need to improve health professionals’ knowledge of the COVID-19 vaccine by providing reliable information regarding vaccine safety, efficacy, and effectiveness. Furthermore, the media outlets need to work to develop trust among the public by disseminating accurate and consistent information about the vaccine. In addition, future researchers should also explore more about the attitude and perception of health care professionals toward the COVID-19 vaccine and its determinants using qualitative data.

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You should checked your manuscript for typos.

Best wishes

Reviewer #2: Generally, there are lots of grammar issues, incohherence of writting methods and results,as a result unrserved effort is recommended to the authors to in crease the quality of the man uscript. All the comments are easily readable with Foxit reader in the manuscript.

**********

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: manuscript.docx

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Submitted filename: PONE-D-21-21414.pdf

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12 Jan 2022

Dear Academic Editor of PLOS ONE journal

Dear Editor, this is regarding the manuscript PONE-D-21-21414 entitled as “Attitude and perception of health professionals towards COVID-19 vaccination and associated factors among health professionals found in Health facilities of Nekemte town, Western Ethiopia” submitted to PLOS ONE. Thanks for your time and consideration in editing and reviewing the manuscript. We have carefully read your comments and corrected inline of reviewer’s comments and suggestions. All comments raised were edited and incorporated in the main manuscript. Some of the changes were highlighted with yellow color in the manuscript. Here are the responses and elaborations for the comments!

Editor and Reviewer comments

The reviewers have raised a number of major concerns. They request improvements to the reporting of methodological aspects of the study, for example, providing more information on the tool used for data collection, the sample size calculation, and ensuring that the manuscript follows STROBE guidelines. In addition, the reviewers also note concerns about the quality of the written English and request that assistance is sought by a native English speaker with experience in scientific writing.

Response: Dear editor, thank you very much, we have addressed these all issues (tool, sample size, language) in the revised manuscript.

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response: Thank you Dear editor, we accepted your comment. All the revision was made in line with the journal requirements including the figure

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Response: Thank you dear, we have addressed this issue in the method part of the manuscript

3. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Response: Thank you, we have included minimal dataset in the revised manuscript as supplementary data

- please provide the reference number for the ethical approval clearance

Response: Thank you dear, we have included reference number in the revised manuscript

- please provide a completed STROBE checklist as an 'Other' file when resubmitting (see https://www.strobe-statement.org/checklists/)

Response: We have included as supplementary file

- please clarify why verbal consent was provided and not written informed consent.

Response: Dear editor, thank you for your question; however, written consent was not obtained from respondents. In Ethiopia, written consent is only possible if a sample is needed from the patients and any invasive procedure is performed. Since, we were not received any blood sample and invasive procedure were not performed; only verbal consent was obtained from participants.

Reviewer #1:

Dear Author,

I have some comments and corrections. I added an MS Word file.

You should edit your manuscript with STROBE guideline.

You should give exact values in the result section.

You should checked your manuscript for typos.

Response: Dear reviewer, Thank you for taking a time to review and edit our work thoroughly. Your effort in editing, and reviewing the overall document for its grammatical and vocabulary problem is very appreciable and valuable. Really, thank you in advance. We have tried to incorporate all your comments and corrections in the main manuscript.

Reviewer #2:

Generally, there are lots of grammar issues, incoherence of writing methods and results, as a result unreserved effort is recommended to the authors to increase the quality of the manuscript. All the comments are easily readable with Foxit reader in the manuscript.

Response: Dear Editor, we are very thankful for your important comment and we have tried to edit the grammatical flaws throughout the manuscript in its revised version. We have edited the spelling, grammatical errors, incomplete and poorly structured sentences throughout the manuscript. Now we believe the revised version is clean and clear enough to the readers.

1. There are lots of grammar issues in the manuscript, please correct it thoroughly?

Response: Thank you dear, we edited the grammatical error throughout the manuscript in its revised version

2. Two different results are reported in the abstract, which was associated with unfavorable attitude, was that good/poor knowledge ?

Response: Thank you dear, we have mentioned the the effect of knowledge on attitude towards the attitude in both result part and conclusion part, with the same message. In result part, it says good knowledge negatively associated with unfavorable attitude (implies having good knowledge about the vaccine could decrease the chance of poor attitude or good knowledge promote favorable attitude). In conclusion section it says poor knowledge positively affects unfavorable attitude, meaning lack of knowledge about the vaccine leads to poor attitude towards the vaccine. To make it clear, we have reported with the same statement in the revised manuscript.

3. One of your outcome, perception was not reported in the abstract section,why?

Response: Thank you dear, we have only one outcome variable (attitude). Perception was not the outcome variable, but we have used as an independent factor. To make it clear, we have removed perception from title in the revised manuscript.

4. Abbreviations/acronyms must be written in full form in first time writing?

Response: kindly accepted your comment

5. There is also a study in Ethiopian population which stating the willingness of Ethiopian population to take the vaccine , it is better to cite it here?

Response: Thank you dear, we have cited studies done in Ethiopia in the revised manuscript.

6. Rlease, correct the punctuation ?

Response: Thank you dear, we have corrected it

7. Repetition of the word ''working'', please delete one of them?

Response: Corrected

8. Your total population is 800. so, why don’t you take either 50% of the population or correction formula, even you can take all of the professionals?

Response: Dear reviewer, we are grateful for this important question. Yes the total population is 800, and the estimated sample size was 439. We used p=50% to estimate the sample size. Our fear to take 50% of the total population was there is scientific background which says use 50% if the total population is 800. From the thumb rule of estimating sample size, it is possible take 50% if the total population is 500. So rather taking 50%, it better to calculate by taking p=50%. In addition, we did not used correction formula, because correction is simply used to save resources. So if we used correction formula the sample size would be less than 250 which could decrease the power of the study.

So, to have a scientific justification and increase the power of the study we used single population proportion formula.

9. Even your expected to give/revisit those health workers who were not on duty during your data collection, why?

Response: Dear, thank you for the question. Duty the urgency of the finding for the research communities we were not revisited the HCW who were on duty leave during data collection. However, we acknowledged this issue in the limitation section.

10. Correct like '' the attitude of health professionals..''

Response: Thank you dear, we have corrected it.

11. Better to say attitude was takes as favorable when the over all score was greater than or equal to the≥ mean.

Response: corrected

12. Please add ''as'' after such.

Response: corrected

13. You should elaborate how do you develop your questions, adapted/adopted/validated/reliability?

Response: Thank you dear, we accepted your comment and incorporated in the revise manuscript

14. You should elaborate how do you develop your questions, adapted/adopted/validated/reliability?

Response: Thank you dear, we have accepted your comment and incorporated in the revised manuscript.

15. Was acceptability/willingness your objective or research question? factors must be fitted towards attitude/perception of COVID 19 vaccine?

Response: Dear reviewer, apologies, it is an technical error, and we have corrected it

16. How do you classify age like this? and use better symbols to make it more standard?

Response: Dear reviewer, thank you for the question. Of course, we need to categorize continuous data into categorical data based on the standards and references, but there was no standard to categorize age for health professionals. We simply categorized age into two categories by reviewing previous article.

17. It is not nearly less than quarter so your expression is not related with your report please correct it like ''only 19 or any other?

Response: Thank you dear, we have accepted your comment.

18. after saying half of, quarter of etc, it is better to add their respective number and percentage consequently?

Response: Thank you dear we have accepted your comment

19. Make it full table title ''where''? the table has grammar issues, correct them?

Response: Thank you dear, we have admitted your comment

20. grammar?

Response: corrected

21. Still you didn,t report the relationship b/n independent variables and perception towards COVID 19? or modify your title accordingly?

Response: Dear reviewer, thank you for this important comment, and we have removed perception from the title.

22. Since your interest variable unfavorable attitude it is better to start by unfavorable/poor attitude in your table?

Response: Thank you dear, we have accepted your comment and incorporated in the revised manuscript

23. You should report firstly to your research question/objective of your study, i.e ''attitude and perceptions of professionals towards COVID 19''? This report is the willingness of the participants?

Response: thank you dear, we have accepted your comment. But, 31.5% is not magnitude of vaccine hesitancy, but the attitude of health professional towards the vaccine hesisatncy. It is one item which was used to assess the attitude of health professionals.

24. your reference system must be either Vancouver or Harvard?

Response: Kindly accepted your comment (Vancouver throughout the manuscript)

25. there is a study done in Ethiopia that showed the willingness to take the vaccine, so it is better to compare with it?

Response: Thank you dear we have reviewed and discussed our finding with previous studies conducted in Ethiopia

26. age < 30 years was significantly associated in your model, but you didn,t discuss it? in addition perceptions of the participants was not reported at all,so either modify your title or please adhere to your objective?

Response: Thank you dear, we have incorporated your concerns in the revised manuscript

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

24 Jan 2022

18 Feb 2022

Dear Academic Editor of PLOS ONE journal

Dear Editor, this is regarding the manuscript PONE-D-21-21414 entitled as “Attitude of health professionals towards COVID-19 vaccination and associated factors among health professionals found in Health facilities of Nekemte town, Western Ethiopia” submitted to PLOS ONE. Thanks for your time and consideration in editing and reviewing the manuscript. We have carefully read your comments and corrected inline of reviewer’s comments and suggestions. All comments raised were edited and incorporated in the main manuscript. Some of the changes were highlighted with yellow color in the manuscript. Here are the responses and elaborations for the comments!

TITLE

Please add the study design in the title, as per the STROBE Guidelines. You might like to revise the title as follows: ‘Attitude of health professionals towards COVID-19 vaccination and associated factors among health professionals in Western Ethiopia: a cross sectional survey’.

Response: revised

ABSTRACT

Introduction:

1. Please delete ‘the’ before towards in this sentence: “…..health professionals the towards the COVID 19 vaccine in resource-limited settings like Ethiopia.”

Response: corrected

2. Please change ‘Hence, this study aimed’ to ‘The aim of study was’ in the following sentence: “Hence, this study aimed to assess health professionals' attitudes and perceptions towards COVID 19 vaccine in West Ethiopia.”

Response: corrected

3. The authors have written ‘Western Ethiopia’ in the title and ‘West Ethiopia’ in the abstract. Please keep the same terminology in the whole manuscript so revise the text thoroughly.

Response: corrected

Results:

4. Please delete ‘were’ in this sentence: “A total of 431 health professionals were participated…..”.

Response: corrected

5. Please change from: ‘The study indicates that…” to ‘The results indicated that..’

Response: corrected

6. Please report p values in the abstract.

Response: corrected

Conclusion:

7. The following statement is not included and supported by the results hence it could be removed: “Therefore, there is still a need to improve health professionals' knowledge of the COVID-19 vaccine by providing reliable information regarding vaccine safety, efficacy, and effectiveness.”

Response: corrected

INTRODUCTION:

8. Please delete ‘and’ before ‘the’ in this sentence “…., and the COVID-19…’

Response: corrected

9. Please delete either ‘coronavirus’ or ‘COVID-19’from this sentence: “According to the worldometer report, the coronavirus COVID-19…”.

Response: corrected

10. Please revise this sentence: “More than 170 million cases, and 3.5 million deaths happened due to COVID-19 [1, 2].” as “More than 170 million cases, and 3.5 million deaths have happened due to COVID-19, as of (add date/month/year) [1, 2].

Response: corrected

11. Please delete ‘health care system challenges;, which is given twice in this sentence: “The pandemic brought the double burden in developing countries already overwhelmed by the health care system challenges already overwhelmed by the health care system challenges [3].”

Response: corrected

12. The following information has become old so it could be omitted and you can name a few COVID vaccines that are being used globally or locally. “Many vaccines started to arise around 2020; there are hundreds of candidate vaccines [7]. As of June 10, 2021, from 287 candidate vaccines, 102 are in the clinical phase, 185 are in the preclinical phase [8]. From these, WHO has listed the Pfizer/BioNTech, Astrazeneca-SK Bio,Serum Institute of India, Janssen and Moderna vaccines for emergency use [6, 7].

Response: corrected

13. Please delete ‘hope of’ from this sentence: Even though people of the world were eagerly waiting for the hope of vaccine development…”

Response: corrected

14. Please delete ‘A’ before ‘studies’ in the following sentence: “A studies conducted in different regions of Ethiopia,….”

Response: corrected

15. Please revise “Several evidence indicates’ to ‘Several studies indicate’….

Response: corrected

16. Please delete ‘now’ in this sentence: “…..9651 deaths till now, May 30, 2021 [1].”

Response: corrected

METHODS:

17. Please change ‘found’ to ‘located’ in this sentence: “This study was conducted in health institutions found in Nekemte town.”

Response: corrected

18. Please add a full stop / period (.) at the end of this sentence: More than 800 health professionals are found in Nekemte town

Response: corrected

19. Sample size: please double check the sample size with15% non-response, as my calculation is a little higher than 439 reported.

Response: Thank you dear, it is a editorial error and we have corrected it

20. Please report who was included/considered as ‘health professionals’. Was it every body working in hospitals or only doctors, nurses and AHPs.

Response: Thank you dear, health professionals were all health care workers in Nekemte town regardless of their profession.

21. Variable mean: The authors report that items were measured on 5 point Likert scale and “Attitude was takes as “favorable” when the overall score was greater than or equal to the mean and less than mean value was rated as an "unfavorable attitude" towards COVID-19 vaccine.” Could you please what were scores for each point of the scale and what was the mean value of the scale scores.

Response: revised in the updated version of manuscript

22. Could you please either refer to relevant table or report 10 items used to measure the attitude and report whether these items were adapted from an earlier survey or developed at home. Please report sources if adapted.

Response: revised in the updated version of manuscript

23. Please either refer to relevant table or report 5 items used to assess the knowledge of health professionals towards the COVID-19 vaccine. Also, report whether these items were adapted from an earlier survey or developed at home. Please report sources if adapted.

Response: revised in the updated version of manuscript

24. Please either refer to relevant table or report 5 items used to measure the perception and report whether these items were adapted from an earlier survey or developed at home. Please report sources if adapted. Could you also report how yes or no were scored.

Response: revised in the updated version of manuscript

25. There is repetition of reporting language in which questionnaire was developed. “The tool was designed and distributed to respondents in English language…”. AND “The questionnaire was prepared in English,..”. Please avoid repetition and revise the text.

Response: revised in the updated version of manuscript

26. Please report the acceptable level of Cronbach’s alpha in the following sentence: “Cronbach’s alpha was used to assess the reliability of the tool.”

Response: included in the revised version of manuscript

27. Please refer questionnaire included as supplementary material.

Response: Hyperlinked

Software:

28. Software: please report citations and references for Epidata and STATA software used.

Response: Cited

Ethics:

29. Please report the data and number of ethics approval by the Ethics Review Board.

Response: ethical clearance number is included in the revised manuscript

RESULTS

30. In the methods section it is reported that the questionnaire was given to health professionals for self- completion while the results section reports that the health professionals were interviewed. Please provide the correct information about how and who completed the questionnaires Either respondents or researchers or both.

Response: Thank you dear, we have corrected it

31. You might like to delete ‘Again in this study’ in this sentence: “Again in this study, greater than half of the participants were vaccinated against coronavirus 240 (55.68%).”

Response: corrected

32. You might like to remove ‘In this study’ from this sentence: “In this study, almost half 210 (48.72 %) of the participants have poor attitude toward COVID-19 vaccination.”

Response: corrected

33. Please change ‘discovered’ to ‘developed’ in the following sentence: “Regarding the effectiveness of the newly discovered COVID-19 vaccination,..”

Response: corrected

34. Table 3: please check the number of respondents for item 3 “Do you think that covid vaccine is mandatory for health care workers?” because the total number is higher than 341 (Yes 262, 60.79%, No 262, 60.79% and I don’t know 145, 33.64%.

Response: corrected

35. Please double check data (counts and %) in all tables.

Response: corrected

DISCUSSION

36. Please revise/change ‘Works of literature are reporting as vaccine..” to ‘Literature shows that as vaccine…

Response: corrected

37. Please change ‘the worries of the peoples’ to ‘the worries of the people…”

Response: corrected

38. Please avoid reporting results in the discussion section like ‘AOR=0.38(95%CI: 0.22, 0.64)).’

Response: corrected

REFERNCES:

39. Please report abbreviations of journal names as reported in the PubMed, if available.

Response: corrected

Submitted filename: response letter.docx

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23 Feb 2022

Attitude of health professionals towards COVID-19 vaccination and associated factors among health professionals, Western Ethiopia: a cross-sectional survey

PONE-D-21-21414R2

Dear Dr. Tolossa,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Syed Ghulam Sarwar Shah, M.B.B.S., M.A., M.Sc., Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The authors need to report journal names in their abbreviated form, which was suggested by the Academic editor in his last report. There are similar articles from the same region of the same country i.e. Ethiopia. Possible duplication or plagiarism may be checked before the acceptance decision is conveyed to the authors.

Reviewers' comments:

28 Feb 2022

PONE-D-21-21414R2

Attitude of health professionals towards COVID-19 vaccination and associated factors among health professionals, Western Ethiopia: a cross-sectional survey

Dear Dr. Tolossa:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Syed Ghulam Sarwar Shah

Academic Editor

PLOS ONE