22 PUBLIC HEALTH, EPIDEMIOLOGY Zdrav Vestn | January – February 2022 | Volume 91 | https://doi.org/10.6016/ZdravVestn.3201 Copyright (c) 2022 Slovenian Medical Journal. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. COVID-19 vaccination intention at the beginning of COVID-19 pandemic in Slovenia Namera cepljenja proti covidu-19 ob začetku pandemije covida-19 v Sloveniji Nevenka Kregar Velikonja,1 Mohsen Hussein,1 Ivan Verdenik,2 Vislava Globevnik Velikonja,2 Karmen Erjavec1 Abstract Background: With the successful development and introduction of vaccines to protect against COVID-19 disease, the pan- demic is expected to end. The success of a vaccination programme depends on the uptake rates in the Slovenian popula- tion and especially among healthcare workers (HCWs), who are at higher risk of infection. Recently, several studies have examined the readiness of different population groups worldwide to be vaccinated. This study compares COVID-19 vacci- nation intentions between lay people and HCWs, and relationships between socio-demographic characteristics, attitudes and beliefs about COVID-19 vaccination, and vaccination intentions reported in the early stages of epidemics. Methods: A cross-sectional study based on an online survey was performed in Slovenia between 13 and 14 March 2020, when the epidemic was officially announced in the country. Data from 2,494 eligible respondents were analysed. Results: The study has shown that 33.2% of all respondents expressed the intention to get vaccinated against COVID-19 disease. This intention was expressed slightly more frequently among HCWs (38.9%) than among lay respondents (30.3%). Men compared to women, older and younger HCWs compared to middle-aged adults, and university graduates compared to HCWs with lower levels of education were more likely to get vaccinated against the disease. More HCWs than lay re- spondents believed that the COVID-19 vaccine would be safe and effective, and they were also more in favour to support vaccination of high-risk groups than mandatory vaccination of the general population. Conclusion: It is critical to communicate the importance of vaccination against COVID-19 appropriately and on a sound scientific basis through various health education programmes and the media, as only one-third of respondents and less than a half of HCWs indicated that they would be willing to get vaccinated once a vaccine is available. Slovenian Medical Journallovenian Medical Journal 1 Faculty of Health Sciences, University of Novo mesto, Novo mesto, Slovenia 2 Division for Obstetrics and Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia Correspondence / Korespondenca: Nevenka Kregar Velikonja, e: nevenka.kregar-velikonja@guest.arnes.si Key words: COVID-19; vaccination; vaccination intention; healthcare professionals Ključne besede: covid-19; cepljenje, namera cepljenja; zdravstveni delavci Received / Prispelo: 20. 12. 2020 | Accepted / Sprejeto: 5. 5. 2021 Cite as / Citirajte kot: Kregar Velikonja N, Hussein M, Verdenik I, Globevnik Velikonja V, Erjavec K. COVID-19 vaccination intention at the beginning of COVID-19 pandemic in Slovenia. Zdrav Vestn. 2022;91(1–2):22–31. DOI: https://doi.org/10.6016/ZdravVestn.3201 eng slo element en article-lang 10.6016/ZdravVestn.3201 doi 20.12.2020 date-received 5.5.2021 date-accepted Public health, epidemiology Javno zdravstvo, epidemiologija discipline Original scientific article Izvirni znanstveni članek article-type COVID-19 vaccination intention at the begin- ning of COVID-19 pandemic in Slovenia Namera cepljenja proti covidu-19 ob začetku pandemije covida-19 v Sloveniji article-title COVID-19 vaccination intention at the begin- ning of COVID-19 pandemic in Slovenia Namera cepljenja proti covidu-19 ob začetku pandemije covida-19 v Sloveniji alt-title COVID-19, vaccination, vaccination intention, healthcare professionals covid-19, cepljenje, namera cepljenja, zdravstveni delavci kwd-group The authors declare that there are no conflicts of interest present. Avtorji so izjavili, da ne obstajajo nobeni konkurenčni interesi. conflict year volume first month last month first page last page 2021 91 1 2 22 31 name surname aff email Nevenka Kregar Velikonja 1 nevenka.kregar-velikonja@guest.arnes.si name surname aff Mohsen Hussein 1 Ivan Verdenik 2 Vislava Globevnik Velikonja 2 Karmen Erjavec 1 eng slo aff-id Faculty of Health Sciences, University of Novo mesto, Novo mesto, Slovenia Fakulteta za zdravstvene vede, Univerza v Novem mestu, Novo mesto, Slovenija 1 Division for Obstetrics and Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia Ginekološka klinika, Univerzitetni klinični center Ljubljana, Ljubljana, Slovenija 2 23 ORIGINAL SCIENTIFIC ARTICLE COVID-19 vaccination intention at the beginning of COVID-19 pandemic in Slovenia 1 Introduction Since its outbreak in China in December 2019, COVID -19 disease has spread so rapidly that the World Health Organization (WHO) declared a global pan- demic on March 11, 2020 (1). In addition to research on prevention, diagnosis and treatment, the success- ful development and introduction of vaccines against COVID-19 disease will be important to reach the pan- demic endpoint. On top of the fact that a COVID-19 vaccine must be safe, elicit a good immune response, and be widely available, the success of a vaccination programme depends on uptake rates in the general population and particularly among health professionals who are at higher risk of infection. Previous research in Slovenia has shown that vaccine confidence is rela- tively low and growing vaccine hesitancy is influenced by internet information sources (2,3). Trust in health professionals is important factor for vaccination accep- tance in general population, e.g. mothers who trusted paediatrician were more likely to be vaccine confident (3). Also physicians’ decision to be vaccinated against seasonal influenza is conditioned by trusting in vac- cination or professional recommendations regarding vaccination and different attitudes regarding vaccina- tion and vaccine-preventable diseases influence (4).To ensure high levels of vaccination coverage, mandato- ry vaccination policy is an important factor in Slove- nia (5). It is important to identify the intentions of the Izvleček Izhodišča: Za obvladovanje pandemije covida-19 je pomemben uspešen razvoj cepiv in izvajanje cepljenja. Uspešnost programov cepljenja je v veliki meri odvisna od tega, kako sprejema cepljenje prebivalstvo in zlasti zdravstveni delavci, pri katerih je tveganje za okužbo večje. V času pandemije je več študij v različnih državah proučevalo pripravljenost raz- ličnih skupin prebivalstva za cepljenje. V naši raziskavi smo primerjali namero za cepljenje proti covidu-19 med splošno populacijo in zdravstvenimi delavci v zgodnji fazi epidemije ter ugotavljali, kako je namera, da se bodo cepili, povezana z njihovimi socialno-demografskimi značilnostmi, stališči in prepričanji o cepljenju proti covidu-19. Metode: Raziskava je bila izvedena v Sloveniji s spletnim anketiranjem v obdobju med 13. in 14. marcem 2020, ko je bila v državi uradno razglašena epidemija. V analizo smo zajeli 2.494 respondentov. Rezultati: Raziskava je pokazala, da je 33,2 % vseh anketiranih izrazilo namero za cepljenje proti bolezni covid-19. Namero za cepljenje je izrazil večji delež zdravstvenih delavcev (38,9 %) kot t.i. laikov (30,3 %). Namero za cepljenje so v večjem deležu izrazili moški kot ženske, med zdravstvenimi delavci pa starejši in mlajši v primerjavi s srednjo generacijo, pa tudi univerzitetno izobraženi v večjem deležu kot tisti z nižjo izobrazbo. Zdravstveni delavci so v večjem deležu menili, da bo cepivo proti covidu-19 učinkovito in varno. Zdravstveni delavci so bili bolj naklonjeni, da se cepijo rizične skupine, kot pa da bi bilo obvezno cepljenje splošne populacije. Zaključek: Glede na ugotovitev, da je komaj tretjina vseh respondentov in manj kot polovica zdravstvenih delavcev izra- zila namero, da so se pripravljeni cepiti takoj, ko bo cepivo na voljo, pa izhaja, kako pomembno je načrtovati in izvajati ustrezne programe zdravstvene vzgoje in informirati o cepljenju proti covidu-19 na osnovi strokovnih dejstev, ki izhajajo iz znanstvenih spoznanj. general population and health professionals in order to prepare and develop effective strategies to maximize uptake once a COVID-19 vaccine is available. Up to date, several studies have investigated fac- tors related to the intention to be vaccinated against COVID-19 in the population (6-12). A global study among 19 countries shows that 71.5% reported they would be very or somewhat likely to take a COVID-19 vaccine. Differences in acceptance across countries ranged from almost 9 in 10 (China) to fewer than 6 in 10 (Russia). Older people were more likely to accept the vaccine. Gender differences were small; men were slightly less likely to respond positively than women (11). According to the US study, 67% of people would accept a COVID-19 vaccine if it was recommended to them. Males (72%) compared to females, older adults (≥ 55 years; 78%) compared to younger adults, and col- lege and/or graduate degree holders (75%) compared to people with less than a college degree were more like- ly to accept the vaccine (10). A European survey (D, F, G, I, P NL, I, UK) on willingness to be vaccinated against COVID 19 has shown that 73.9% participants stated that they would be willing to get vaccinated against COVID-19 if a vaccine would be available. A significantly higher proportion of men were willing to get vaccinated (77.94%) than women (70.15%). The willingness to be vaccinated is the highest among those 24 PUBLIC HEALTH, EPIDEMIOLOGY Zdrav Vestn | January – February 2022 | Volume 91 | https://doi.org/10.6016/ZdravVestn.3201 above the age of 55 (12). Southeast Asian study revealed that acceptance of a COVID-19 vaccine is highly in- fluenced by the perception of vaccine effectiveness (8). British study on different factors associated with vacci- nation acceptability found that 64% of participants re- ported being likely to be vaccinated against COVID-19. Personal and clinical characteristics, previous influen- za vaccination, general vaccination beliefs, and beliefs and attitudes about COVID-19 and a COVID-19 vac- cination explained 77% variance in vaccination in- tention (6). Intention to be vaccinated was associated with more positive general COVID-19 vaccination be- liefs and attitudes, weaker beliefs that the vaccination would cause side effects or be unsafe, greater perceived risk of COVID-19 to others but not oneself, older age, and having been vaccinated for influenza last winter (2019/20) (7). Apart from the fact that the risk of being infected by COVID-19 is higher in HCWs than in the general population (13-14), HCWs are also crucial to perform adequate health education of general population to un- derstand and accept vaccination. A Southeast Asian study found that the acceptance of a vaccine against COVID-19 is higher among health care workers than in the lay population, which is based on a higher per- ceived risk of COVID-19 infection (8). A Chinese study found that there is a higher tolerance for future vaccina- tions in HCWs than in the general population. 76.4% of HCWs (compared to 72.5% in the general population) showed their willingness to be vaccinated. In contrast, for the lay population, vaccine safety and decisions on social contacts were the most important predictors (15). Since HCWs are the key information sources and the strongest influencing factors in vaccination deci- sions by people (16-17), it is vital to understand how the main socio-demographic factors and opinion are associated with the vaccination intention. The aim of this study was to assess the COVID-19 vaccination intention of the general population and HCWs, and the relations between socio-demographic characteristics, attitudes and beliefs about COVID-19 vaccination and vaccination intention. 2 Methods The research work was based on a survey in which the data were collected with the voluntary participa- tion of anonymous participants. The online survey was distributed using snowball sampling which is in line with previous similar studies (18-19). Target groups were health professionals (HCWs) and lay persons. The initial group of respondents were contacted via profes- sional (HCWs) and personal contacts (laics) of project members and the link to the survey was disseminated further via social network Facebook. Participants were asked to complete a self-administrated, structured elec- tronic questionnaire. The survey was active for 24 hours from 13 March at 2:20 pm, to 14 March at 2:20 pm. The survey was accessed by 18,760 individuals, 12,305 of which responded to it, with 8,023 responses being appropriate for further analysis, and 7,764 com- pletely filled out the questionnaire. There were 87.2% female and 12.7% male respondents. Their age ranged from 13 to 83 years (average 38.2), with 4.8% aged 65 years or more. As many as 42.9% of the respondents completed secondary school education, 53.3% had a graduate degree, and 4.6% a postgraduate degree; 14% of respondents belonged to healthcare sector. To measure vaccination intention, respondents were asked to use answers “yes”, “no” or “I do not know”, to the question whether they would be definitely vaccinat- ed when a coronavirus vaccination became available to them. To measure respondents’ attitudes towards COVID-19 in relation to the vaccinated population, three claims were made: “Vaccination should be man- datory for all”, “Vaccination should be recommended for people over 65” and “Vaccination should be recom- mended for people with chronic diseases”. In addition, respondents’ opinions about the safety (“I believe the vaccine will be safe”) and the effectiveness of COVID-19 vaccines (“I believe the vaccine will be effective”) and their attitude towards the vaccination in general (“I am categorically against the use of vaccines”), were record- ed. The question about any previous influenza vacci- nation was also asked. Previous research reported that fear of adverse side effects and perceived vaccine inef- fectiveness were the main reasons for vaccine hesitancy (20). For the case-control study about the effect of health professionals’ attitude and practice of vaccination, we used the propensity score (PS) method. Two controls were selected for each health professional respondent among all lay respondents (n = 6,664) using PS match- ing. In the PS model, we included age as a continuous variable, education as a categorical variable (4 catego- ries), and gender as a dichotomous variable. We per- formed 1:2 matching with an optimal matching algo- rithm. After the matching protocol was applied, 832 HCWs and a corresponding control sample of 1,662 individuals (from 6,664 lay respondents) were selected for further analysis, together 2,494 respondents. For statistical calculations, we used statistical 25 ORIGINAL SCIENTIFIC ARTICLE COVID-19 vaccination intention at the beginning of COVID-19 pandemic in Slovenia program IBM SPSS Statistics for Windows, Version 25.0 and R (21) with R-package “Matchlt” (22). For all calculation Chi-square test was used and a two-sided probability (p) value < 0.05 was considered statistically significant. The study protocol was reviewed and approved by the Ethical Committee at the Faculty of Health Scienc- es, University of Novo mesto (approval number FZV- 98/2020, 10. 3. 2020). 3 Results About one-third of all respondents stated that they would intend to be vaccinated against COVID-19 dis- ease. Almost half of them did not know whether they would decide to be vaccinated. Statistically significant- ly more HCWs intended to be vaccinated comparing to lay respondents as shown in Table 1. Less HCWs were undecided to be vaccinated against COVID-19 disease compared to lay respondents. Statistically significantly less HCWs stated that they were categorically against vaccination than lay respondents. More HCWs than lay respondents believed that the vaccine would be safe and effective. Less HCWs than lay respondents expressed uncertainty about the safety and efficacy of the vaccine. Slightly less HCWs than laics argued that vaccination should be mandatory for all. However, more HCWs than lay respondents felt that the vaccine should be recom- mended for vulnerable groups. Statistically significantly more men than women ex- pressed their intention to be vaccinated. Table 2 shows the results by gender differences in the lay respondents and HCWs – in both groups, men are more in favour of vaccination. When asked who should be vaccinated, there was statistically significant gender difference in HCWs where women in higher percentage state that Table 1: Attitudes about a COVID-19 vaccination by (non-)healthcare profession. Yes No Don't know p value I will definitely get vaccinated. HCWs 324 (38.9%) 180 (21.6%) 328 (39.4%) LRs 503 (30.3%) 356 (21.4%) 801 (48.3%) 0.001 Vaccination should be mandatory for all. HCWs 255 (30.6%) 300 (36.1%) 277 (33.3%) LRs 551 (33.2%) 506 (30.5%) 603 (36.3%) 0.019 Vaccination should be recommended for people over 65. HCWs 713 (85.7%) 28 (3.4%) 91 (10.9%) LRs 1301 (78.3%) 76 (4.6%) 284 (17.1%) 0.001 Vaccination should be recommended for people with chronic diseases. HCWs 717 (86.2%) 32 (3.8%) 83 (10.0%) LRs 1303 (78.4%) 73 (4.4%) 285 (17.2%) 0.001 I believe the vaccine will be effective. HCWs 216 (26.0%) 110 (13.2%) 506 (60.8%) LRs 334 (20.1%) 180 (10.8%) 1145 (69.0%) 0.001 I believe the vaccine will be safe. HCWs 256 (30.8%) 109 (13.1%) 466 (56.1%) LRs 378 (22.7%) 215 (12.9%) 1069 (64.3%) 0.001 I am categorically against the use of vaccines. HCWs 79 (9.5%) 695 (83.5%) 58 (7.0%) LRs 203 (12.2%) 1267 (76.3%) 191 (11.5%) 0.001 Legend: HCWs – health care professionals; LRs – lay respondents; n = 2494. 26 PUBLIC HEALTH, EPIDEMIOLOGY Zdrav Vestn | January – February 2022 | Volume 91 | https://doi.org/10.6016/ZdravVestn.3201 vaccination should be recommended to elderly and to people with chronic diseases. There is a statistically sig- nificant gender difference in the assumption that the vaccine would be safe and effective in lay respondents (where men express more trust in safety and effective- ness of vaccine and are less against vaccination), but not in HCW’s. There is no statistically significant difference among Table 2: Beliefs and attitudes about COVID-19 vaccination of health care professionals (HCWs) and lay respondents (LRs) by gender. HCWs (n = 832) LRs (n = 1662) Total Yes No Don't know Yes No Don't know (n = 2494) I will definitely get vaccinated. Men 50.5% 21.5% 28.0% 38.8% 23.9% 37.3% Women 37.2% 21.7% 41.1% 29.1% 21.1% 49.8% p value 0.01 0.02 0.001 Vaccination should be mandatory for all. Men 31.8% 36.4% 31.8% 37.8% 29.7% 32.5% Women 30.5% 36.0% 33.5% 32.5% 30.6% 36.9% p value 0.932 0.283 0.322 Vaccination should be recommended for people over 65. Men 80.4% 7.5% 12.1% 77.9% 5.3% 16.8% Women 86.5% 2.8% 10.8% 78.4% 4.5% 17.1% p value 0.034 0.869 0.203 Vaccination should be recommended for people with chronic diseases. Men 80.4% 9.3% 10.3% 75.0% 4.8% 20.2% Women 87.0% 3.0% 9.9% 78.9 4.3% 16.7% p value 0.06 0.422 0.057 I believe the vaccine will be effective. Men 31.8% 12.1% 56.1% 30.1% 6.7% 63.2% Women 25.1% 13.4% 61.5% 18.7% 11.4% 69.9% p value 0.340 0.001 0.001 I believe the vaccine will be safe. Men 38.3% 15.0% 46.7% 37.1% 11.9% 51.0% Women 29.7% 12.8% 57.7% 20.7% 13.1% 66.3% p value 0.107 0.001 0.001 I am categorically against the use of vaccines. Men 8.4% 86.9% 4.7% 10% 82.8% 7.2% Women 9.7% 83.0% 7.3% 12.5% 75.3% 12.1% p value 0.535 0.047 0.026 Legend: HCWs – health care professionals; LRs – lay respondents. respondents with different educational levels in relation to vaccination intentions, either in HCWs or in laics (Ta- ble 3). The proportion of those who believed that vacci- nation should be mandatory for all decreased statistical- ly significantly in laics as education levels increased, but not in HCWs. The belief that vulnerable groups should be vaccinated does not differ significantly in HCWs and laics according to education level. HCWs with a Table 3: Beliefs and attitudes about a COVID-19 vaccination of health care professionals (HCWs) and lay respondents (LRs) by education levels. HCWs (n = 832) LRs (n = 1662) Total Yes No Don't know Yes No Don't know (n = 2494) I will definitely get vaccinated. Secondary school 35.0% 24.2% 40.7% 31.4% 19.4% 49.2% Graduate level 41.1% 19.6% 39.3% 29.5% 23.5% 47.0% Postgraduate level 50% 21.1% 28.9% 29.6% 16.9% 53.5% p value 0.219 0.337 0.496 Vaccination should be mandatory for all. Secondary school 33.6% 36.5% 29.9% 39.2% 24.3% 36.4% Graduate level 28.9% 34.8% 36.3% 28.7% 35.1% 36.2% Postgraduate level 23.7% 47.4% 28.9% 28.2% 35.2% 36.6% p value 0.077 0.001 0.001 Vaccination should be recommended for people over 65. Secondary school 84.3% 4.0% 11.7% 78.2% 5.1% 16.7% Graduate level 87.4% 2.5% 10.1% 78.2% 4.3% 17.4% Postgraduate level 78.9% 7.9% 13.2% 80.3% 2.8% 16.9% p value 0.426 0.833 0.925 Vaccination should be recommended for people with chronic diseases. Secondary school 89.1% 2.6% 8.3% 79.8% 4.6% 15.6% Graduate level 87.4% 3.4% 9.2% 77.2% 4.3% 18.5% Postgraduate level 78.9% 7.9% 13.2% 78.9% 2.8% 18.3% p value 0.685 0.275 0.739 I believe the vaccine will be effective. Secondary school 21.4% 16.5% 62.1% 19.5% 10.4% 70.1% Graduate level 27.8% 10.8% 61.4% 20.3% 11.8% 67.9% Postgraduate level 47.4% 10.5% 42.1% 23.9% 2.8% 73.3% p value 0.002 0.246 0.039 I believe the vaccine will be safe. Secondary school 25.7% 16.0% 58.3% 22.0% 12.3% 65.7% Graduate level 33.4% 11.1% 55.5% 22.8% 10.3% 66.9% Postgraduate level 47.4% 10.5% 42.1% 25.7% 16.9% 58.3% p value 0.018 0.467 0.064 I am categorically against the use of vaccines. Secondary school 12.8% 78.3% 8.8% 12.9% 74.1% 13.0% Graduate level 6.8% 87.3% 5.9% 11.8% 77.7% 10.5% Postgraduate level 10.5% 86.8% 2.7% 10.0% 81.4% 8.6% p value 0.180 0.075 0.005 Legend: HCWs – health care professionals; LRs – lay respondents. 27 ORIGINAL SCIENTIFIC ARTICLE COVID-19 vaccination intention at the beginning of COVID-19 pandemic in Slovenia respondents with different educational levels in relation to vaccination intentions, either in HCWs or in laics (Ta- ble 3). The proportion of those who believed that vacci- nation should be mandatory for all decreased statistical- ly significantly in laics as education levels increased, but not in HCWs. The belief that vulnerable groups should be vaccinated does not differ significantly in HCWs and laics according to education level. HCWs with a Table 3: Beliefs and attitudes about a COVID-19 vaccination of health care professionals (HCWs) and lay respondents (LRs) by education levels. HCWs (n = 832) LRs (n = 1662) Total Yes No Don't know Yes No Don't know (n = 2494) I will definitely get vaccinated. Secondary school 35.0% 24.2% 40.7% 31.4% 19.4% 49.2% Graduate level 41.1% 19.6% 39.3% 29.5% 23.5% 47.0% Postgraduate level 50% 21.1% 28.9% 29.6% 16.9% 53.5% p value 0.219 0.337 0.496 Vaccination should be mandatory for all. Secondary school 33.6% 36.5% 29.9% 39.2% 24.3% 36.4% Graduate level 28.9% 34.8% 36.3% 28.7% 35.1% 36.2% Postgraduate level 23.7% 47.4% 28.9% 28.2% 35.2% 36.6% p value 0.077 0.001 0.001 Vaccination should be recommended for people over 65. Secondary school 84.3% 4.0% 11.7% 78.2% 5.1% 16.7% Graduate level 87.4% 2.5% 10.1% 78.2% 4.3% 17.4% Postgraduate level 78.9% 7.9% 13.2% 80.3% 2.8% 16.9% p value 0.426 0.833 0.925 Vaccination should be recommended for people with chronic diseases. Secondary school 89.1% 2.6% 8.3% 79.8% 4.6% 15.6% Graduate level 87.4% 3.4% 9.2% 77.2% 4.3% 18.5% Postgraduate level 78.9% 7.9% 13.2% 78.9% 2.8% 18.3% p value 0.685 0.275 0.739 I believe the vaccine will be effective. Secondary school 21.4% 16.5% 62.1% 19.5% 10.4% 70.1% Graduate level 27.8% 10.8% 61.4% 20.3% 11.8% 67.9% Postgraduate level 47.4% 10.5% 42.1% 23.9% 2.8% 73.3% p value 0.002 0.246 0.039 I believe the vaccine will be safe. Secondary school 25.7% 16.0% 58.3% 22.0% 12.3% 65.7% Graduate level 33.4% 11.1% 55.5% 22.8% 10.3% 66.9% Postgraduate level 47.4% 10.5% 42.1% 25.7% 16.9% 58.3% p value 0.018 0.467 0.064 I am categorically against the use of vaccines. Secondary school 12.8% 78.3% 8.8% 12.9% 74.1% 13.0% Graduate level 6.8% 87.3% 5.9% 11.8% 77.7% 10.5% Postgraduate level 10.5% 86.8% 2.7% 10.0% 81.4% 8.6% p value 0.180 0.075 0.005 Legend: HCWs – health care professionals; LRs – lay respondents. 28 PUBLIC HEALTH, EPIDEMIOLOGY Zdrav Vestn | January – February 2022 | Volume 91 | https://doi.org/10.6016/ZdravVestn.3201 postgraduate degree mostly stated that the vaccine was effective. There is no statistically significant difference in the education level of this opinion in lay respondents. As regards vaccination safety, there is a statistically sig- nificant difference in the education level of respondents among HCWs, but not among laics. There is no statisti- cally significant difference in the level of education of re- spondents among HCWs and laics in their categorically negative attitude towards vaccines. There is a statistically significant age difference in HCWs and laics in terms of vaccination intention and mandatory vaccination. A higher percentage of younger and older respondents among HCWs and laics expressed an intention to be vaccinated compared to middle-aged respondents, claiming that vaccination should be man- datory for all and believing that the vaccine was effec- tive and safe (Table 4). There is no statistically significant age difference in the effectiveness of the vaccine in la- ics; however, a higher percentage of younger and older respondents among HCWs expressed a belief that the vaccine would be effective. There is a statistically signifi- cant age difference in the belief that the vaccine would be safe. As regards age, neither HCWs nor lay respondents statistically significantly differ in their categorically neg- ative attitude toward vaccines. 4 Discussion The aim of the study was to analyse vaccination in- tention and vaccination acceptance in healthcare pro- fessionals in comparison with lay persons. The study showed that 33.2% of all respondents expressed inten- tion to be vaccinated against COVID-19 disease. Almost half of them (45.3%) did not know whether they would be vaccinated. In a group of lay respondents, 30.3% of respondents stated that they would be vaccinated. Males compared to females, older and younger adults com- pared to middle age adults, and postgraduate degree holders compared to people with less than graduate level of education were more likely to get vaccinated. Accord- ing to other studies on vaccination intention in the early stage of pandemic (6-812), the results differ in view of the low proportion of respondents willing to get vaccinat- ed. Lower vaccination intention is not surprising, since the Slovenian study on the views of key stakeholders on vaccination found out that the proportion of mothers of children who trust in vaccination is not high (47%) (17). The results also differ from other studies on vaccination intention in the early stage of pandemic (6-12) with re- spect to the low proportion of middle-aged respondents who intend to be vaccinated against Covid-19. This may Table 4: Beliefs and attitudes about COVID-19 vaccination of health care professionals (HCWs) and lay respondents (LRs) by age. HCWs (n = 832) LRs (n = 1662) Total Yes No Don't know Yes No Don't know (n = 2494) I will definitely get vaccinated. 0-19 52.6% 21.1% 26.3% 43.2% 6.0% 50.0% 20-29 38.0% 24.6% 37.4% 39.5% 17.5% 42.9% 30-39 39.0% 21.3% 39.7% 26.9% 25.8% 47.2% 40-49 37.2% 21.1% 41.7% 23.8% 24.0% 52.2% 50-59 39.7% 18.3% 42.1% 31.7% 16.3% 52.0% 60+ 56.3% 31.3% 12.5% 38.2% 17.6% 44.1% p value 0.0442 0.001 0.001 Vaccination should be mandatory for all. 0-19 57.9% 26.3% 15.8% 52.3% 9.1% 38.6% 20-29 28.5% 43.0% 28.5% 35.3% 26.6% 38.1% 30-39 26.8% 37.9% 35.3% 28.7% 35.9% 35.5% 40-49 27.5% 35.8% 36.7% 30.1% 35.9% 34.0% 50-59 42.9% 25.4% 31.7% 39.9% 21.7% 38.3% 60+ 31.3% 31.3% 37.5% 47.1% 11.8% 41.2% p value 0.001 0.010 0.001 Vaccination should be recommended for people over 65. p value 0.312 0.284 0.395 Vaccination should be recommended for people with chronic diseases. p value 0.156 0.066 0.309 I believe the vaccine will be effective. 0-19 15.8% 52.6% 31.6% 13.6% 22.7% 63.6% 20-29 16.2% 29.1% 54.7% 8.8% 28.0% 63.2% 30-39 12.1% 26.5% 61.4% 14.6% 20.3% 65.1% 40-49 11.0% 22.0% 67.0% 10.7% 16.1% 73.1% 50-59 13.5% 23.8% 62.7% 6.3% 15.0% 78.7% 60+ 18.8% 18.8% 62.5% 5.9% 17.6% 76.5% p value 0.001 0.080 0.001 I believe the vaccine will be safe. 0-19 5.3% 52.6% 42.1% 9.1% 31.8% 59.1% 20-29 13.4% 39.7% 46.9% 10.7% 32.5% 56.8% 30-39 15.5% 29.2% 55.4% 16.4% 23.9% 59.7% 40-49 10.1% 27.5% 62.4% 12.4% 17.0% 70.6% 50-59 12.7% 23.8% 63.5% 11.4% 14.2% 74.4% 60+ 25.0% 31.3% 43.8% 5.9% 26.5% 67.6% p value 0.020 0.001 0.001 I am categorically against the use of vaccines. p value 0.665 0.199 0.069 Legend: HCWs – health care professionals; LRs – lay respondents. be explained by the fact that the majority of representa- tives of the middle generation or “sandwich generation” in Slovenia is extremely burdened and averse to various additional obligations, such as in our case vaccination (23). The study showed statistically significant differenc- es between HCWs and lay people, but these differenc- es were relatively small. More HCWs (38.9%) than lay respondents (30.3%) expressed a clear intention to get vaccinated against COVID-19 disease. Interestingly, in a study performed in Slovenia in December 2020, 33% of respondents indicated that they definitively intended to participate in vaccination and 26% replied that they would probably agree to vaccination; in total, 59% in- tended to get vaccinated (24). Vaccination intention was very high in physicians and medical students, however vaccination intention in other healthcare professionals and healthcare students was similar to general popula- tion (24). Our study however did not collect data about different healthcare professionals. Similar results have also been found in PANDA-SI survey preformed period- ically every 2 weeks since December 2020, where 45.8% to 57.8% respondents intended to get vaccinated (25). Men compared to women, older and younger HCWs compared to middle-aged adults, and postgraduate de- gree holders compared to HCWs with lower level of education were more likely to get vaccinated. More of them also believed that the COVID-19 vaccine would be safe and effective, and they were more in favour of vac- cinating high-risk groups and less in favour of manda- tory vaccination than lay people. This is consistent with the findings of an earlier Slovenian study, which found that while most Slovenian healthcare practitioners have confidence in vaccination safety, they have reservations about vaccination itself, and only about half of them get regularly vaccinated against influenza (17). Surprisingly, there was no statistically significant difference between education levels with respect to vac- cination intentions, either within a group or between groups. This may be due to the fact that attitudes them- selves, and especially attitudes toward vaccination, are a psychological construct, a complex mental and emo- tional entity that is not related to the cognitive features alone (26). This means that we cannot acquire them rationally or change them through education, but that emotional and social influences are also important in their expression. One possible reason for the low affin- ity to vaccination is that previous communication did not take into account the emotional dimension or was too much based on hierarchical and even intimidating communication, against which Slovenian people usually 29 ORIGINAL SCIENTIFIC ARTICLE COVID-19 vaccination intention at the beginning of COVID-19 pandemic in Slovenia postgraduate degree mostly stated that the vaccine was effective. There is no statistically significant difference in the education level of this opinion in lay respondents. As regards vaccination safety, there is a statistically sig- nificant difference in the education level of respondents among HCWs, but not among laics. There is no statisti- cally significant difference in the level of education of re- spondents among HCWs and laics in their categorically negative attitude towards vaccines. There is a statistically significant age difference in HCWs and laics in terms of vaccination intention and mandatory vaccination. A higher percentage of younger and older respondents among HCWs and laics expressed an intention to be vaccinated compared to middle-aged respondents, claiming that vaccination should be man- datory for all and believing that the vaccine was effec- tive and safe (Table 4). There is no statistically significant age difference in the effectiveness of the vaccine in la- ics; however, a higher percentage of younger and older respondents among HCWs expressed a belief that the vaccine would be effective. There is a statistically signifi- cant age difference in the belief that the vaccine would be safe. As regards age, neither HCWs nor lay respondents statistically significantly differ in their categorically neg- ative attitude toward vaccines. 4 Discussion The aim of the study was to analyse vaccination in- tention and vaccination acceptance in healthcare pro- fessionals in comparison with lay persons. The study showed that 33.2% of all respondents expressed inten- tion to be vaccinated against COVID-19 disease. Almost half of them (45.3%) did not know whether they would be vaccinated. In a group of lay respondents, 30.3% of respondents stated that they would be vaccinated. Males compared to females, older and younger adults com- pared to middle age adults, and postgraduate degree holders compared to people with less than graduate level of education were more likely to get vaccinated. Accord- ing to other studies on vaccination intention in the early stage of pandemic (6-812), the results differ in view of the low proportion of respondents willing to get vaccinat- ed. Lower vaccination intention is not surprising, since the Slovenian study on the views of key stakeholders on vaccination found out that the proportion of mothers of children who trust in vaccination is not high (47%) (17). The results also differ from other studies on vaccination intention in the early stage of pandemic (6-12) with re- spect to the low proportion of middle-aged respondents who intend to be vaccinated against Covid-19. This may Table 4: Beliefs and attitudes about COVID-19 vaccination of health care professionals (HCWs) and lay respondents (LRs) by age. HCWs (n = 832) LRs (n = 1662) Total Yes No Don't know Yes No Don't know (n = 2494) I will definitely get vaccinated. 0-19 52.6% 21.1% 26.3% 43.2% 6.0% 50.0% 20-29 38.0% 24.6% 37.4% 39.5% 17.5% 42.9% 30-39 39.0% 21.3% 39.7% 26.9% 25.8% 47.2% 40-49 37.2% 21.1% 41.7% 23.8% 24.0% 52.2% 50-59 39.7% 18.3% 42.1% 31.7% 16.3% 52.0% 60+ 56.3% 31.3% 12.5% 38.2% 17.6% 44.1% p value 0.0442 0.001 0.001 Vaccination should be mandatory for all. 0-19 57.9% 26.3% 15.8% 52.3% 9.1% 38.6% 20-29 28.5% 43.0% 28.5% 35.3% 26.6% 38.1% 30-39 26.8% 37.9% 35.3% 28.7% 35.9% 35.5% 40-49 27.5% 35.8% 36.7% 30.1% 35.9% 34.0% 50-59 42.9% 25.4% 31.7% 39.9% 21.7% 38.3% 60+ 31.3% 31.3% 37.5% 47.1% 11.8% 41.2% p value 0.001 0.010 0.001 Vaccination should be recommended for people over 65. p value 0.312 0.284 0.395 Vaccination should be recommended for people with chronic diseases. p value 0.156 0.066 0.309 I believe the vaccine will be effective. 0-19 15.8% 52.6% 31.6% 13.6% 22.7% 63.6% 20-29 16.2% 29.1% 54.7% 8.8% 28.0% 63.2% 30-39 12.1% 26.5% 61.4% 14.6% 20.3% 65.1% 40-49 11.0% 22.0% 67.0% 10.7% 16.1% 73.1% 50-59 13.5% 23.8% 62.7% 6.3% 15.0% 78.7% 60+ 18.8% 18.8% 62.5% 5.9% 17.6% 76.5% p value 0.001 0.080 0.001 I believe the vaccine will be safe. 0-19 5.3% 52.6% 42.1% 9.1% 31.8% 59.1% 20-29 13.4% 39.7% 46.9% 10.7% 32.5% 56.8% 30-39 15.5% 29.2% 55.4% 16.4% 23.9% 59.7% 40-49 10.1% 27.5% 62.4% 12.4% 17.0% 70.6% 50-59 12.7% 23.8% 63.5% 11.4% 14.2% 74.4% 60+ 25.0% 31.3% 43.8% 5.9% 26.5% 67.6% p value 0.020 0.001 0.001 I am categorically against the use of vaccines. p value 0.665 0.199 0.069 Legend: HCWs – health care professionals; LRs – lay respondents. 30 PUBLIC HEALTH, EPIDEMIOLOGY Zdrav Vestn | January – February 2022 | Volume 91 | https://doi.org/10.6016/ZdravVestn.3201 resist (27). Affinity to vaccination is one of the predictors that should be taken into account in modelling of the dynamics of the disease or in estimating the impact of intervention strategies (28). As previous studies on vaccination acceptance and intention to vaccinate have shown, these phenomena are strongly influenced by trust (29). This was also demon- strated during the first wave of the COVID-19 pandem- ic, when studies showed an association between trust in health and government agencies (30,31) or vaccine safe- ty (32-34) and vaccination intention. 5 Conclusion Since only one-third of respondents and less than half of HCWs indicated that they would be willing to get vaccinated once a vaccine is available, it is important to communicate the importance of vaccination against COVID-19 appropriately and on a sound scientific basis through various health education programmes. 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