Determinants of COVID‐19 vaccine uptake among healthcare professionals and the general population in Cyprus: A web‐based cross‐sectional survey

Abstract Objective This study aims to examine the factors influencing COVID‐19 vaccine uptake among healthcare professionals (HCPs) and the general population in Cyprus. Methods A web‐based cross‐sectional study was conducted (November 2021–January 2022), using a self‐administered, anonymous questionnaire to collect information covering a wide range of potential determinants including sociodemographic and health‐related characteristics, trust in the healthcare system, satisfaction with it, utilization of preventive healthcare services, COVID‐19 vaccination information and general vaccination knowledge. Results A total of 2582 participants completed the survey. Overall, 53.5% of participants representing the general population, and 70.0% of the HCPs received the COVID‐19 vaccination. We found that as the age increases by 1 year among the general population, the odds of being vaccinated against COVID‐19 increase by 1.02 units (95% 1.00, 1.03, p= 0.035). In addition, participants among the general population with increased trust in national healthcare authorities' guidelines (OR = 3.96, 95% CI: 3.41, 4.61), and increased vaccination knowledge scores (OR = 1.11, 95% CI: 1.05, 1.18) were significantly more likely to be vaccinated, while those who had underage children living in the household were significantly less likely to be vaccinated against COVID‐19 (OR = 0.68, 95% CI: 0.50, 0.91). Furthermore, male HCPs (OR = 1.91, 95% CI: 1.01, 3.59), and those who reported increased trust in national healthcare authorities' guidelines (OR = 5.38, 95% CI: 3.65, 7.95) were significantly more likely to be vaccinated. Conclusion Public health policymakers can use national campaigns and long‐term planning to build public trust in national healthcare authorities and raise awareness about the benefits of vaccination. Such strategies could pave the way for adequate vaccine uptake and prepare the public for unfavourable scenarios, such as future pandemics.


| INTRODUCTION
The severe acute respiratory syndrome coronavirus 2 (SARS-  was firstly detected in 2019 and is responsible for the coronavirus disease 2019 . Since its appearance, SARS-CoV-2 spread worldwide, and the World Health Organization declared the first coronavirus pandemic in human history in March 2020. 1 By March 2022 more than 470,000,000 humans have been infected by SARS-CoV-2 and approximately 6,000,000 lost their life. 2 Most people with COVID-19 experienced mild to moderate symptoms, but some developed life-threatening illnesses and post-COVID-19 conditions with long-term effects. 3 Beyond the impact of COVID-19 on individuals' physical health, the COVID-19 pandemic also affected their mental health and social interaction. 4,5 Several vaccines against COVID-19 have been approved and distributed around the globe; however, vaccine hesitancy remains a crucial public health challenge. 6 Vaccine hesitancy refers to refusal or delayed acceptance of vaccines, hence beset herd immunity achievement. 7 The process of vaccine acceptance is a multidimensional and context-specific topic that varies depending on the specific vaccine, time and place. 7,8 Different levels of COVID-19 vaccine acceptance have been reported across the world, with a large proportion of healthcare professionals (HCPs) and public members refusing the COVID-19 vaccine in some countries. 6,9,10 Among the reasons for COVID-19 vaccination refusal were the fear of possible side effects, and concerns over the safety and efficacy of the vaccine. 11 A growing body of literature recognizes the importance of trust in health services and confidence in the importance of vaccines as influential factors for COVID-19 vaccination acceptance. Individual's confidence in the usefulness of vaccines, accurate information providence, trust in doctors and the healthcare system, discussions with medical staff about the vaccine importance and previous medical records such as uptake of influenza vaccine are factors that are associated with the COVID-19 vaccination acceptance. [12][13][14] Furthermore, the level of misinformation about the usefulness of vaccines, which is often linked with a lack of trust in science is negatively associated with the COVID-19 vaccination acceptance. [15][16][17] Professionals in the healthcare sector may have different vaccination knowledge levels, trust in healthcare services and generally different determinants for COVID-19 vaccination acceptance compared to the general population. However, evidence is scarce on the different determinants that influence HCPs and the general population to get vaccinated against COVID-19. In Cyprus, studies have identified a low COVID-19 vaccination acceptance among HCPs with vaccination knowledge being an associated factor for COVID-19 vaccine acceptance. [18][19][20] Also, inadequate COVID-19 vaccine uptake among the general population of Cyprus was recently identified (54% of 2117 participants). 21 It is critical to gain a comprehensive understanding of the factors that influence vaccination uptake so that future advertising campaigns and government interventions can be more effectively targeted. Therefore, this study aims to examine the factors influencing COVID-19 vaccine uptake among the HCPs and the general population in Cyprus.

| Study design, participants and data collection
This study was reported following the Strengthening the Reporting of Observational Studies in Epidemiology. 22 This was a web-based cross-sectional survey performed between the 15th of November 2021 and the 7th of January 2022. The referent population included Greek-Cypriot, aged 18 years old and above, living in the five government-controlled municipalities of the Republic of Cyprus (Nicosia, Limassol, Larnaca, Paphos and Ammochostos). A nonprobability convenience sampling approach was used to recruit participants using an online self-administered questionnaire, created in Google Forms, and dispersed using instant messaging apps (e.g., WhatsApp, Viber), social media platforms (e.g., Facebook, Instagram), and social networking sites (e.g., LinkedIn). Additional methodological details of this study have been presented elsewhere. 21 [24][25][26][27][28][29][30] Face validity was assessed in a pilot study of 50 participants before the actual study to assess the clarity and application of all survey items, as well as to address wording issues.
Cronbach's alpha coefficient for internal reliability for the section regarding the attitudes towards healthcare services section was 0.68, while for vaccination knowledge items were 0.71.

| Ethics approval
This study was approved by the Cyprus National Bioethics Committee (CNBC) (ΕΕΒΚ ΕΠ 2021.01.219). All participants were informed about the research aims and objectives before taking part and that all data would be used only for research purposes. Participation was completely anonymous and voluntary. Participants consent to take part in research before completing the online questionnaire by answering a "Yes/No" question on a mandatory electronic form.

| Statistical analysis
Shapiro-Wilk normality test was applied to examine the normality of the continuous variables. Participants' characteristics are presented as mean ± SD for continuous measures with normal distribution, while continuous characteristics with skewed distributions are presented as median with interquartile range (IQR). Absolute (n) and relative (%) frequencies were used to present categorical variables (i.e., gender, geographical area). In the analysis, we divide our study population into two groups: participants representing the general population of Cyprus and HCPs. To assess the association between COVID-19 vaccination status and the categorical character-   Table 1). There was a total of 504 HCPs in the study among whom 223 (48%) were nursing staff, 76 (16.3%) were pharmacists, 73 (15.7%) were physicians, 62 (13.3%) were other nonmedical professionals (i.e., laboratory workers, nutritionists, occupational therapists, psychologists, radiologists, speech and language therapists, care assistants and administrative personnel) and 31 (6.7%) were physiotherapists.  Table 1).
Specific sociodemographic characteristics of participants representing the general population of Cyprus were associated with their COVID-19 vaccination status. Many participants in the general population who had underage children living in the household were unvaccinated (n = 556, 50.7%), while most of the participants without underage children were vaccinated (n = 558, 58.3%) (p < 0.001). The largest statistically significant differences between vaccination status groups were reported among those who had completed a postgraduate education (39.5% vs. 60.5%, for no and yes, respectively, p < 0.001) and participants who had an annual income of more than 19,500 euros (41.8% vs. 58.2%, for no and yes, respectively, p < 0.001) ( Table 1).
As regards the COVID-19 vaccination by HCPs, we reported that 350 (70.0%) were vaccinated against COVID-19. A statistically significant difference was identified among HCPs who had an annual income of more than 19,500 euros (25.2% vs. 74.8%, for no and yes, respectively, p = 0.006) ( Table 1).
Around 19% (n = 482) of the participants reported at least one chronic disease, while most of the participants used preventive healthcare services (n = 874, 34.0%) moderately. We also reported that a similar number of participants had no trust (n= 680, 26.5%) or a strong trust (n = 693, 27.0%) in the official guidelines and recommendations of the national healthcare authorities. Moreover, many participants were moderately satisfied with the healthcare system GIANNAKOU ET AL. The participants' mean vaccination knowledge score was 6.9 (SD = 2.6) which indicates a low to moderate vaccination knowledge. p < 0.001; Table 3).
To identify independent determinants of COVID-19 vaccination coverage, hierarchical logistic regression modelling was applied (Supporting Information:  The link between older age and higher vaccination uptake among the sample of the general population could be explained in different ways. For example, older individuals are more susceptible to COVID-19 and considered themselves more vulnerable. [39][40][41] In addition, it is known that the influenza vaccination is recommended for individuals aged ≤65 years old due to a higher risk of disease severity, hospitalization as well as death by influenza infection. 42 Hence, it is possible that older individuals and those with chronic diseases prefer to be vaccinated against influenza and COVID-19 too. 43 It is also important to acknowledge the early availability of COVID-19 vaccines to older and immunocompromised individuals which can impact the vaccination uptake among the different aged populations. However, other studies found that younger individuals are more likely to accept the COVID-19 vaccine compared to older individuals. [44][45][46] We also observed that the presence of underage children in the household was associated with a lower probability of COVID-19 vaccination uptake. This finding is consistent with other research studies, 40,47,48 however, the reasons contributing to the observed outcome need further investigation. A possible explanation could be the parental fear of any long-term health problem caused by the vaccine that will interfere with their ability to raise their children.

| Sources of information about vaccination
Supporting this hypothesis, a recent study showed that only a small percentage of mothers in Greece did not have doubts about the efficacy and safety of new vaccines. 49 The same study also showed that the majority of participants are against the immediate vaccination of children after the release of new vaccines. 49 In addition, many COVID-19 vaccines were not approved for young children, so parents may think vaccines were unsafe for their children and themselves.
Our study also found that increased level of general vaccination knowledge was significantly associated with the uptake of the Also, we were unable to calculate the response rate for our webbased survey because there is no way of knowing how many individuals saw the survey or its links but chose not to participate.
Finally, these findings apply solely to the population of Cyprus and cannot be generalized to other countries.

| CONCLUSIONS
To our knowledge, this is the first study that provides insights