Article
COVID-19 Vaccine Booster Hesitancy (VBH) of Healthcare
Workers in Czechia: National Cross-Sectional Study
Miloslav Klugar 1,2,3 , Abanoub Riad 1,4,* , Lekshmi Mohanan 1 and Andrea Pokorná 1,2,3
Citation: Klugar, M.; Riad, A.;
Mohanan, L.; Pokorná, A. COVID-19
Vaccine Booster Hesitancy (VBH) of
Healthcare Workers in Czechia:
National Cross-Sectional Study.
Vaccines 2021, 9, 1437. https://
doi.org/10.3390/vaccines9121437
Academic Editors: Claudia Maria
Trombetta, Emanuele Montomoli and
Serena Marchi
Received: 17 November 2021
Accepted: 3 December 2021
Published: 6 December 2021
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4.0/).
1 Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic,
Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Faculty of Medicine, Institute of
Biostatistics and Analyses, Masaryk University, 625 00 Brno, Czech Republic; klugar@med.muni.cz (M.K.);
lekshmi.mohanan@mail.muni.cz (L.M.); apokorna@med.muni.cz (A.P.)
2 Department of Health Sciences, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
3 Institute of Health Information and Statistics of the Czech Republic, 128 01 Prague, Czech Republic
4 Department of Public Health, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
* Correspondence: abanoub.riad@med.muni.cz
Abstract: The emerging SARS-CoV-2 variants and waning vaccine-elicited immunity are two public
health challenges that occurred simultaneously and synergistically during the summer of 2021 and
led to a surging demand for COVID-19 vaccine booster dose (BD) rollout. This study aimed to
evaluate the COVID-19 vaccine booster hesitancy (VBH) among Czech healthcare workers to explore
the potential determinants of VBH. A national cross-sectional survey-based study was carried out
between 3 and 11 November 2021, using an online self-administered questionnaire (SAQ) that
explored the participants’ demographic characteristics, COVID-19 infection and vaccine anamneses,
willingness to receive COVID-19 vaccine BD, and the psychosocial drivers of VBH. A total of 3454
HCW properly responded to the online SAQ, of which 80.9% were females, 30.3% were medical
professionals, and 50.5% were ≤47 years old. Most of the participants were already inoculated
against SARS-CoV-2 (95.2%), and BTN162b2 was the most commonly administered vaccine (90.7%).
As the study sample was planned to represent the target population, it revealed a high level of BD
acceptance (71.3%) among Czech HCW, while 12.2% were still hesitant and 16.6% were against the
currently available BD. These results are consistent with other recent results from central Europe.
Medical professional, male, and older participants were more likely to accept BD rather than allied
health professional, female, and younger participants. The BDs’ perceived effectiveness against
severe illness, symptomatic infection, and community transmission was a significant and strong
predictor for BD acceptance, while the effectiveness against the circulating variants was not that
important for our target population. The BDs’ perceived safety and ethical dilemmas of vaccine
justice should be addressed sufficiently while communicating with HCW and other population
groups. The altruistic reasons for BD acceptance, i.e., family protection, patient protection, and
community health protection, underpin the recommendation of postponing the COVID-19 vaccine
mandating in favour of stressing these altruistic concerns amid public health messaging.
Keywords: booster immunization; COVID-19 vaccines; Czechia; decision making; health personnel
1. Introduction
Healthcare workers (HCW) have experienced disproportionately high levels of COVID-
19-associated morbidity and mortality; therefore, they were prioritized for receiving
COVID-19 vaccine booster doses (BDs), which are the third doses of two-dose vaccines, such
as BNT162b2 and mRNA-1273, or the second doses of 1-dose vaccines such as Ad26.COV2.S,
along with those aged above 65 and the immunocompromised population [1,2]. Since
the epidemic flare-ups and effective vaccines’ accessibility are long-standing challenges,
distrust of vaccines’ BDs has been increasingly reported, especially in the last few years,
triggered by anti-vaccination campaigns [3–5].
Vaccines 2021, 9, 1437. https://doi.org/10.3390/vaccines9121437 https://www.mdpi.com/journal/vaccines
Vaccines 2021, 9, 1437 2 of 29
Recent reports have been increasingly suggesting that the effectiveness of COVID-
19 vaccines had declined in several countries within 6 months after the primer doses’
rollout [6–9]. The recorded epidemic flare-ups and breakthrough cases had been attributed
to two possibilities; (a) the emerging variants (mutations) of the severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2), or (b) the waning vaccine-elicited immunity that is
challenged by the heightened immune evasion by the circulating variants, e.g., the Delta
variant, which were not known at the time of the vaccine development and can partially
bypass the protective mechanisms established after vaccination and cause illness, leaving
the vaccinated cohorts vulnerable [7–12]. As both phenomena occur simultaneously and
synergistically, the duty of epidemiologic and public health researchers to clarify this foggy
scene and provide evidence-informed recommendations regarding the COVID-19 vaccines’
BD timing and priority groups became a challenging one.
It was clearly evident in population-level studies from Scotland, the United States, and
Qatar that protection from COVID-19 symptomatic infection can be expected from the twodose
vaccination regimes that were effective against the Delta variant (B.1.617.2) [13–15].
Likewise, protection from severe illness can also be achieved according to the population
studies of Canada, Scotland, and the United Kingdom, especially against the Alpha variant
(B.1.1.7) [9,13,16]. However, the same studies noted a slight drop in the effectiveness of
COVID-19 vaccines to around 80%; the sustained reduction in infection risk underscores
the continued importance and benefits of COVID-19 vaccination [17]. The good news is that
further population studies showed a significant decrease in relative risk of symptomatic
infection and severe illness in the patients who received a COVID-19 vaccine BD [18,19].
Therefore, the rollout of BDs -including COVID-19 vaccine BDs- has always been required
to battle some of the deadliest diseases, e.g., Hepatitis B and pertussis, which are seen most
commonly among HCWs due to their frequent use exposure [20,21].
Vaccine hesitancy (VH) is defined by the World Health Organization (WHO) Strategic
Advisory Group of Experts on Immunization (SAGE) as “delay in acceptance or refusal of
vaccination despite the availability of vaccination services” [22]. COVID-19 vaccine BD
hesitancy (VBH) can be predicted in populations with suboptimal vaccine uptake, such
as in Poland, where only 51% of the population received a first dose until the middle of
September 2021, despite the extensive scientific communication efforts and the worsening
epidemic situation in the country in 2021 [23].
Vaccine selectivity (VS) is another emerging public health challenge which can be
defined as “the discriminatory attitudes towards certain types of vaccines based on their
target contagion or manufacturing technology that yields heterogeneous acceptance levels
of recommended vaccines”, and can be simply understood as the individual’s or public’s
preference of particular vaccine/s based on their mode of action or brand rather than
general preference of immunization [24]. This phenomenon has been commonly seen with
childhood vaccines, as parents can be selective with certain vaccines that they believe
effective and/or safe for their children, and decline other vaccines [25]. A similar situation
had been reportedly experienced with COVID-19 vaccines due to the diversity of vaccine
options in many countries, which created a pseudo-competitive ecology for comparing and
choosing among the available vaccine brands in the market [26].
An average vaccinee may accept or reject a BD due to various triggers, including; the
side effects experienced after the previous (primer) doses, perceived effectiveness of the
BD, the vaccinee’s susceptibility to the target infection, and safety uncertainties [23,27].
The WHO-SAGE depicted the perceived effectiveness, safety, and susceptibility and the
cost-benefit ratio evaluation as critical determinants for VH, especially for the childhood
vaccines which are conventionally recommended worldwide [28–31].
The safety of COVID-19 vaccines as novel pharmacologic products is a chief priority
for health systems that aim to keep tracking them during the post-marketing (phase IV)
period through their passive surveillance systems, e.g., VAERS, CAEFISS, and MHRAYellow
Cards [32–34]. In addition, active surveillance studies and hybrid systems had been
strongly advocated, especially with the accelerated rollout of COVID-19 vaccines [35–38].
Vaccines 2021, 9, 1437 3 of 29
However, there is still a lack of peer-reviewed evidence on COVID-19 vaccines’ BD side
effects; the preliminary findings from passive surveillance systems and the population
study of Israel suggest that the BD side effects are not different from the primer doses
side effects [18,39,40]. The primer doses were found to induce mild side effects in the vast
majority of vaccinees, which lasted for 1–3 days on average in most of COVID-19 vaccines
types, i.e., mRNA-based, viral vector-based, and inactivated virus vaccines [24,41–48].
The risk of waning immunity and development of suboptimal immune response after
vaccination in older and immunocompromised people, e.g., oncologic patients, organ
transplant recipients, and HIV patients, even after two-dose regimens, led to the consensus
recommendation of prioritizing these high-risk groups for COVID-19 vaccine BD in various
countries, e.g., the United States and France [12,49–52]. HCWs as a defined high-risk group
for COVID-19 infection were also prioritized in all countries that started the rollout of
COVID-19 vaccine BDs in late summer 2021, including the Czech Republic [2].
The holistic aim of this study was to evaluate the COVID-19 VBH among HCWs in
Czechia. The primary objective was to assess the levels of COVID-19 vaccine BD acceptance
and hesitancy among HCWs, and the secondary objective was to explore the potential
demographic, anamnestic, and psychosocial determinants of the COVID-19 VBH among
the target population.
2. Materials and Methods
2.1. Design
An analytical survey-based cross-sectional study was carried out between 3–11 November
2021 to explore the attitudes of Czech healthcare workers towards receiving the BD
(third) doses of COVID-19 vaccines. The study utilized a self-administered questionnaire
(SAQ) which was coded and disseminated online through KoBoToolbox (Harvard Humanitarian
Initiative, Cambridge, MA, USA, 2021) for data collection from the target
participants [53]. The Strengthening the Reporting of Observational Studies in Epidemiology
(STROBE) guidelines for cross-sectional studies governed the design, conduction, and
reporting of this study [54].
2.2. Participants
As a nationwide study, the target population (healthcare workers) was approached
through various channels, aiming to achieve a nationally representative sample. A nonrandom
technique (snowballing strategy) was used to recruit the participants from all the
fourteen regions of the Czech Republic. On 1 November 2021, invitations were sent to
the chairs of the professional medical societies, which are members of the Czech Medical
Association of J. E. Purkynˇe (CzMA; Prague, Czech Republic), the member institutions coordinators
of the Czech Clinical Research Infrastructure Network (CZECRIN; Brno, Czech
Republic), and the inpatient healthcare facilities managers within the network of the Central
Adverse Events Reporting System of the Institute of Health Information and Statistics of
the Czech Republic (IHIS-CR; Prague, Czech Republic) in order to facilitate participation in
the study by circulating the survey uniform resource locator (URL) through their respective
networks [55–57]. Another channel was used in collaboration with the Ministry of Health to
also include healthcare providers for inpatient long-term care; the professional association
of non-medical healthcare workers, i.e., Czech Nursing Association ( ˇCAS) [58], Union
of Physical Therapists of the Czech Republic (UNIFY- ˇCR) [59], Chamber of Midwives of
the Czech Republic ( ˇCKPA) [60], Association of College Nurses (SVVS) [61], Association
of Higher Education Educators in the Non-Medical Health Professions (AVVNZP) [62],
and Association of Social Service Providers of the Czech Republic (APSS- ˇCR) [63]. The
study was further promoted through the official websites of professional medical and allied
healthcare societies, in addition to the website of the Czech Ministry of Health (MoH) [64].
Epi-Info TM version 7.2.4 (CDC. Atlanta, GA, USA, 2020) was used to calculate the
optimal sample size required for this study [65]. The population survey module was run
following the assumptions of 2% margin of error, 95% confidence level (CI), 50% outcome
Vaccines 2021, 9, 1437 4 of 29
probability, and a target population size of 257,118 based on the latest report of IHISCR
[66,67]. The required sample size was 2379 participants (Supplementary Figure S1).
Participation in this study was entirely voluntary, thus implying that the participants
were not forced or rewarded to participate. Additionally, participation in this study was
anonymous, to give the participants room to freely express their views and attitudes
towards vaccination, aiming to eliminate Hawthorne bias.
Until 11 November 2021, 3563 responses were received, of which 101 were excluded
because the participants did not consent to participate in the study after reading the
informed consent, constituting 2.8% as a non-repose rate. Later, eight responses were
removed due to incomplete data, leading to a final sample of 3454 participants being
included in the final analyses (Figure 1).
Figure 1. Workflow of COVID-19 Vaccine BD Survey among Czech Healthcare Workers, November
2021 (n = 3454).
2.3. Instrument
The draft SAQ was adapted from previous studies of COVID-19 vaccine hesitancy
and consisted of 19 close-ended items stratified into five sections [68–75]. The first section,
demographic characteristics, included gender, age, profession, and region. The second
section, COVID-19-related anamnesis, included the history of COVID-19 infection, onset,
clinical severity, and manifestations of the infection. The third section, COVID-19 vaccinerelated
anamnesis, included the history of COVID-19 vaccination, vaccine type, and the
number of doses. The fourth section included a five-point Likert scale item assessing the
Vaccines 2021, 9, 1437 5 of 29
willingness to receive BD of COVID-19 vaccines, ranging from “Totally Disagree = 1” to
“Totally Agree = 1”.
The fifth section had a set of potential psychosocial drivers of COVID-19 vaccine BD
acceptance, including (a) perceived effectiveness: preventing severe illness, symptomatic
infection, and community transmission and controlling variants (mutations), (b) perceived
safety: equal safety profile compared to primer doses, and seriousness of side effects, (c)
perceived susceptibility and risk-benefit ratio, (d) moral dilemma of vaccine justice, and (e)
vaccine primer dose satisfaction and vaccine selectivity.
The content validity of the draft SAQ was assessed by a panel of experts in public
health medicine, health policy, and healthcare management who provided their feedback
on relevance appropriateness and clarity of the proposed items. The experts’ comments
guided the development of the pre-test version of the SAQ which was sent to target
volunteers who filled it twice with a 14-day interval. The test-re-test reliability of the
SAQ yielded a mean Cohen’s kappa coefficient of 0.80 ± 0.19 (IQR: 0.60–1.00), indicating a
substantial level of reliability according to McHugh’s criteria [76] (Supplementary Table S1).
2.4. Ethics
The declaration of Helsinki for research involving human subjects guided the design
and execution of this study [77]. The study protocol was thoroughly reviewed by the Ethics
Committee of the Faculty of Medicine at Masaryk University on 19 October 2021 under the
identifier Ref. 63/2021.
All participants had to provide their informed consent as a prerequisite to taking part
in the study. The participants were offered to leave the study at any time without justifying
their decision; also, no data was saved before the participants finalized the questionnaire
and confirmed submitting their answers. No identifying personal data were collected from
the participants, in order to keep the study as much anonymous as possible and aiming for
the elimination of the Hawthorne bias. The European Union (EU) General Data Protection
Regulation (GDPR) was followed during data collection and processing [78].
2.5. Statistics
Statistical analyses were performed using the Statistical Package for the Social Sciences
(SPSS) version 28.0 (SPSS Inc. Chicago, IL, USA, 2020) [79]. Initially, the normal distribution
of numerical variables, e.g., age, was tested using the Shapiro-Wilk test. Descriptive
statistics were performed to present all the study variables; nominal variables, e.g., gender,
profession and discrete events, and ordinal variables, e.g., psychosocial drivers, had been
described using frequencies (n) and proportions (%). The numerical variables, e.g., age,
had been described using central tendency and dispersion properties.
Consequently, inferential statistics were performed to test for the associations between
independent demographic variables (profession, age group, and gender), anamnestic
variables (COVID-19 infection and vaccine primer doses), psychosocial drivers, and the
dependent variable of BD-related attitudes using the Chi-squared test (χ2) and Fisher’s
exact test for tests with <5 predicted frequency. Eventually, univariate logistic regression
was performed to evaluate the odds ratio of vaccine hesitancy vs. acceptance for each
significant demographic variable. Multivariate regression analysis of the proposed psychosocial
drivers was adjusted for gender, pregnancy, age, profession, COVID-19 infection
and vaccination, and seeking medical care. All inferential tests were run with the following
assumptions; a confidence level (CI) of 95% and significance level (Sig.) of ≤0.05.
3. Results
3.1. Demographic Characteristics
Out of 3454 participants, females were the majority (80.9%), followed by males (18.6%)
and LGBTQ+ (0.4%). There were 25 pregnant women among the participating females, of
which 36% were in the first trimester, 40% the second trimester, and 24% the third trimester.
Vaccines 2021, 9, 1437 6 of 29
The mean age of the participants was 46.97 ± 11.78 (IQR: 39–55) years old, and the median
was 47 years old Table 1.
Table 1. Demographic Characteristics of Czech Healthcare Workers Responding to COVID-19 Vaccine
BD Survey, November 2021 (n = 3454).
Variable Outcome Frequency (n) Percentage (%)
Gender
Female † 2796 80.9%
Male 643 18.6%
LGBTQ+ 15 0.4%
† Pregnancy
Yes ‡ 25 0.9%
No 2771 99.1%
‡ Trimester
1st Trimester 9 36%
2nd Trimester 10 40%
3rd Trimester 6 24%
Age
≤47 years-old 1744 50.5%
>47 years-old 1710 49.5%
Profession
Medical Professionals (MP) 1047 30.3%
Allied Health Professionals (AHP) 2407 69.7%
No missing data. † Female participants. ‡ Pregnant participants.
According to Czech law, Act no. 95/2004 Coll. and Act no. 96/2004 Coll., medical
professions (MP) include general medicine, dentistry, and pharmacy, while allied health
professions (AHP) include all the non-medical professions which are related to the provision
of health care, e.g., nursing, midwifery, and physiotherapy [80–82]. Physicians were
the most common MP (28.4%), followed by pharmacists (1.5%) and dentists (0.4%). General
nurses were the most common AHP (42%), followed by paediatric nurses (4.3%), medical
laboratory technicians (4.2%), and pharmaceutical assistants (3.0%). In total, MP represented
30.3% of the participating sample, while AHP represented 69.7% (Supplementary
Table S1).
The participating sample represented all the fourteen administrative regions of the
Czech Republic, Act no. 129/2000 Coll. [83]. The most contributing region was the capital
city Prague (29.2%), followed by the South Moravian (20.2%), the Central Bohemian (9.8%),
the Moravian-Silesian (6.0%), and the Ústecký regions (5.4%), shown in Figure 2.
3.2. COVID-19-Related Anamnesis
In total, 32% of the participants reported being previously infected with COVID-19,
with a significant difference between MP (28.4%) vs. AHP (33.6%) and >47 years-old
(29.5%) vs. ≤47 years-old (34.5%). Most infections (87.8%) occurred before receiving the
first COVID-19 vaccine dose, 6.2% between the first and the second doses, and 6.0% after
the second dose. According to the Australian guidelines for the clinical care of people
with COVID-19, mild cases were the majority (59.5%), followed by moderate (31.4%) and
asymptomatic (7.1%) [84]. There was no statistically significant difference in COVID-19
onset or severity across the profession, gender, or age group.
The most commonly reported clinical manifestation of COVID-19 infection was fatigue
(77.1%), followed by myalgia (66.2%), headache (63.3%), anosmia (59.9%), fever (56.4%),
cough (49.9%), and dysgeusia (46.2%). Dyspnea was significantly more common among
females (30.6%) and AHP (32.8%) compared to males (21.0%) and MP (18.5%). Neurological
disorders, i.e., anosmia and dysgeusia, were significantly more common among
AHP, females, and the ≤47 year-old group than MP, males, and the >47 year-old group,
respectively. Headache, pharyngitis, congestion, and nausea were significantly more common
among females than males. Headache, nausea, and vomiting were significantly more
common among AHP than MP (Table 2).
Vaccines 2021, 9, 1437 7 of 29
Figure 2. Geographic Distribution of Czech Healthcare Workers Responding to COVID-19 Vaccine BD Survey, November
2021 (n = 3454).
3.3. COVID-19 Vaccine-Related Anamnesis
The vast majority (95.2%) of the participating sample had received primer doses of
COVID-19 vaccines. There were slight differences in vaccine uptake favouring MP, males,
and >47 years-old compared to their counterparts. The most reportedly administered
vaccine was BTN162b2 (90.7%), followed by mRNA-1273 (5.3%), AZD1222 (2.7%), and
Ad26.COV2.S (1.3%). MP (95.1%) and males (92.8%) had significantly more BTN162b2
compared to AHP (88.7%) and females (92.8%). There were no gender or age-based
differences in terms of the administered vaccine type.
Less than half of the sample received a third dose by the time of responding to this
survey (48.5%), and the rest received either two doses (49.7%) or one dose (1.8%). MP
received significantly (Sig. < 0.001) more three doses (60.2%) than AHP (43.3%). Likewise,
males received significantly (Sig. < 0.001) more three doses (60.6%) than females (45.8%).
Only 2.2% of the total participants reported seeking medical care following the COVID-19
vaccine primer doses; three reported anaphylaxis, 26 lymphadenopathy, 67 myalgia, 67
arthralgia, 58 fatigue, 70 fever, 17 vomiting, and 65 headache (Table 3).
Vaccines 2021, 9, 1437 8 of 29
Table 2. COVID-19-related Anamnesis of Czech Healthcare Workers Responding to COVID-19 Vaccine BD Survey, November 2021 (n = 3454).
Variable Outcome
Medical
Professionals
(n = 1047)
Allied Health
Professionals
(n = 2407)
Sig.
Female
(n = 2796)
Male
(n = 643)
Sig.
≤47 Years
(n = 1744)
>47 Years
(n = 1710)
Sig.
Total
(n = 3454)
Infection
Yes † 297 (28.4%) 809 (33.6%) 0.002 908 (32.5%) 195 (30.3%) 0.293 602 (34.5%) 504 (29.5%) 0.001 1106 (32.0%)
No 750 (71.6%) 1598 (66.4%) 1888 (67.5%) 448 (69.7%) 1142 (65.5%) 1206 (70.5%) 2348 (68.0%)
† Onset
Before 1st
Dose
257 (86.5%) 714 (88.3%) 0.437 793 (87.3%) 175 (89.7%) 0.352 527 (87.5%) 444 (88.1%) 0.779 971 (87.8%)
Between Doses 22 (7.4%) 47 (5.8%) 0.330 57 (6.3%) 12 (6.2%) 0.948 41 (6.8%) 28 (5.6%) 0.390 69 (6.2%)
After 2nd Dose 18 (6.1%) 48 (5.9%) 0.937 58 (6.4%) 8 (4.1%) 0.222 34 (5.6%) 32 (6.3%) 0.624 66 (6.0%)
† Severity
Asymptomatic 17 (5.7%) 62 (7.7%) 0.267 61 (6.7%) 18 (9.2%) 0.217 39 (6.5%) 40 (7.9%) 0.348 79 (7.1%)
Mild 188 (63.3%) 470 (58.1%) 0.118 542 (59.7%) 114 (58.5%) 0.751 392 (65.1%) 266 (52.8%) <0.001 658 (59.5%)
Moderate 84 (28.3%) 263 (32.5%) 0.179 290 (31.9%) 56 (28.7%) 0.379 164 (27.2%) 183 (36.3%) 0.001 347 (31.4%)
Severe 5 (1.7%) 13 (1.6%) 1.000 * 13 (1.4%) 5 (2.6%) 0.344 * 6 (1.0%) 12 (2.4%) 0.070 18 (1.6%)
Critic 3 (1.0%) 1 (0.1%) 0.062 * 2 (0.2%) 2 (0.1%) 0.146 * 1 (0.2%) 3 (0.6%) 0.336 * 4 (0.4%)
† Sign &
Symptoms
Fever 185 (62.3%) 439 (54.3%) 0.017 502 (55.3%) 119 (61.0%) 0.143 331 (55.0%) 293 (58.1%) 0.292 624 (56.4%)
Cough 149 (50.2%) 403 (49.8%) 0.917 461 (50.8%) 90 (46.2%) 0.242 293 (48.7%) 259 (51.4%) 0.368 552 (49.9%)
Dyspnea 55 (18.5%) 265 (32.8%) <0.001 278 (30.6%) 41 (21.0%) 0.007 160 (26.6%) 160 (31.7%) 0.059 320 (28.9%)
Fatigue 229 (77.1%) 624 (77.1%) 0.992 705 (77.6%) 145 (74.4%) 0.322 458 (76.1%) 395 (78.4%) 0.366 853 (77.1%)
Myalgia 194 (65.3%) 538 (66.5%) 0.713 601 (66.2%) 128 (65.6%) 0.883 406 (67.4%) 326 (64.7%) 0.334 732 (66.2%)
Headache 167 (56.2%) 533 (65.9%) 0.003 601 (66.2%) 97 (49.7%) <0.001 394 (65.4%) 306 (60.7%) 0.104 700 (63.3%)
Anosmia 163 (54.9%) 500 (61.8%) 0.037 574 (63.2%) 87 (44.6%) <0.001 398 (66.1%) 265 (52.6%) <0.001 663 (59.9%)
Dysgeusia 115 (38.7%) 396 (48.9%) 0.002 444 (48.9%) 65 (33.3%) <0.001 296 (49.2%) 215 (42.7%) 0.031 511 (46.2%)
Pharyngitis 54 (18.2%) 148 (18.3%) 0.966 177 (19.5%) 25 (12.8%) 0.029 110 (18.3%) 92 (18.3%) 0.994 202 (18.3%)
Congestion 104 (35.0%) 261 (32.3%) 0.388 319 (35.1%) 46 (23.6%) 0.002 228 (37.9%) 137 (27.2%) <0.001 365 (33.0%)
Rhinitis 100 (33.7%) 256 (31.6%) 0.523 301 (33.1%) 55 (28.2%) 0.180 208 (34.6%) 148 (29.4%) 0.066 356 (32.2%)
Nausea 29 (9.8%) 128 (15.8%) 0.011 142 (15.6%) 14 (7.2%) 0.002 74 (12.3%) 83 (16.5%) 0.048 157 (14.2%)
Vomiting 6 (2.0%) 49 (6.1%) 0.006 49 (5.4%) 6 (3.1%) 0.177 29 (4.8%) 26 (5.2%) 0.795 55 (5.0%)
Diarrhea 46 (15.5%) 159 (19.7%) 0.114 173 (19.1%) 31 (15.9%) 0.303 96 (15.9%) 109 (21.6%) 0.015 205 (18.5%)
Chi-squared test (χ2) and Fisher’s exact test (*) had been used with a significance level (Sig.) ≤ 0.05. † COVID-19 Infection. The significant associations are in bold font.
Vaccines 2021, 9, 1437 9 of 29
Table 3. COVID-19 Vaccine-related Anamnesis of Czech Healthcare Workers Responding to COVID-19 Vaccine BD Survey, November 2021 (n = 3454).
Variable Outcome
Medical
Professionals
(n = 1047)
Allied Health
Professionals
(n = 2407)
Sig.
Female
(n = 2796)
Male
(n = 643)
Sig.
≤47 Years
(n = 1744)
>47 Years
(n = 1710)
Sig.
Total
(n = 3454)
Vaccinated
Yes † 1012 (96.7%) 2275 (94.5%) 0.007 2651 (94.8%) 625 (97.2%) 0.010 1637 (93.9%) 1650 (96.5%) <0.001 3287 (95.2%)
No 35 (3.3%) 132 (5.5%) 145 (5.2%) 18 (2.8%) 107 (6.1%) 60 (3.5%) 167 (4.8%)
† Vaccine
Type
BTN162b2 962 (95.1%) 2018 (88.7%) <0.001 2390 (90.2%) 580 (92.8%) 0.041 1481 (90.5%) 1499 (90.8%) 0.710 2980 (90.7%)
mRNA-1273 19 (1.9%) 156 (6.9%) <0.001 155 (5.8%) 20 (3.2%) 0.008 100 (6.1%) 75 (4.5%) 0.046 175 (5.3%)
AZD1222 20 (2.0%) 68 (3.0%) 0.097 70 (2.6%) 17 (2.7%) 0.911 36 (2.2%) 52 (3.2%) 0.091 88 (2.7%)
Ad26.COV2.S 11 (1.1%) 33 (1.5%) 0.402 36 (1.4%) 8 (1.3%) 0.879 20 (1.2%) 24 (1.5%) 0.561 44 (1.3%)
† Doses
Number
One 16 (1.6%) 43 (1.9%) 0.539 50 (1.5%) 9 (1.4%) 0.451 29 (1.8%) 30 (1.8%) 0.918 59 (1.8%)
Two 387 (38.2%) 1246 (54.7%) <0.001 1388 (52.4%) 237 (37.9%) <0.001 907 (55.4%) 726 (44.0%) <0.001 1633 (49.7%)
Three 609 (60.2%) 986 (43.3%) <0.001 1213 (45.8%) 379 (60.6%) <0.001 701 (42.8%) 894 (54.2%) <0.001 1595 (48.5%)
† Medical
Care
Yes 23 (2.3%) 90 (4.0%) 0.014 98 (3.7%) 13 (2.1%) 0.044 64 (3.9%) 49 (3.0%) 0.139 113 (3.4%)
No 989 (97.7%) 2185 (96.0%) 2553 (96.3%) 612 (97.9%) 1573 (96.1%) 1601 (97.0%) 3174 (96.6%)
Chi-squared test (χ2) had been used with a significance level (Sig.) ≤ 0.05. † COVID-19 Vaccination. The significant associations are in bold font.
Vaccines 2021, 9, 1437 10 of 29
3.4. COVID-19 Vaccine BD-Related Attitudes
When asked about their attitudes towards receiving COVID-19 vaccine BDs, 71.3%
indicated their acceptance (“totally agree” and “agree”), 12.2% were hesitant (“not sure”),
and 16.5% disclosed their rejection to receive the BD (“totally disagree” and “disagree”). MP
(77.7%), male (79.3%), and >47 year-old participants (76.5%) had significantly (Sig. < 0.001;
<0.001; and <0.001) higher levels of BD acceptance than AHP (68.6%), female (69.7%), and
≤47 year-old participants (66.3%), (Figure 3).
Figure 3. COVID-19 Vaccine BD-related Attitudes of Czech Healthcare Workers Responding to COVID-19 Vaccine BD
Survey, November 2021 (n = 3454).
The BD-accepting group was asked about their motivators for receiving the BD; the
most common promoter was to protect their families (83.0%), followed by protecting their
own health (82.7%), protecting their patients (70.4%), community health protection (66.4%),
and having lesser restrictions on the social activities, e.g., travel (49.8%). Employer’s
endorsement was reported as the motivator for only 3.4% of the participants.
MP had significantly (Sig. < 0.001; and <0.001) higher levels of interest in patients’
protection and community health protection (74.8% and 76.0%, respectively) compared
to AHP (68.2% and 61.7%, respectively). Similarly, male participants had a significantly
(Sig. < 0.001) higher level of interest in community health protection (73.7%) than their
female counterparts (64.4%), (Table 4).
3.5. Psychosocial Drivers of BD-Related Attitudes
The perceived effectiveness of BDs was assessed through four items; (i) severe illness,
(ii) symptomatic infection, (iii) community transmission, and (iv) mutation control. A
total of 80.3% of the participants agreed that the current BD could protect them from
severe illness, while only 57.8% agreed that BDs could prevent symptomatic infection. A
total of 60.8% and 65.1% of the participants agreed that BDs could prevent community
transmission and tackle the new circulating variants, respectively.
Vaccines 2021, 9, 1437 11 of 29
Table 4. COVID-19 Vaccine-related Attitudes of Czech Healthcare Workers Responding to COVID-19 Vaccine BD Survey, November 2021 (n = 3454).
Variable Outcome
Medical
Professionals
(n = 1047)
Allied Health
Professionals
(n = 2407)
Sig.
Female
(n = 2796)
Male
(n = 643)
Sig.
≤47 Years
(n = 1744)
>47 Years
(n = 1710)
Sig.
Total
(n = 3454)
Attitudes
Rejection 154 (14.7%) 416 (17.3%) 0.061 468 (16.7%) 93 (14.5%) 0.159 344 (19.7%) 226 (13.2%) <0.001 570 (16.5%)
Hesitancy 80 (7.6%) 340 (14.1%) <0.001 379 (13.6%) 40 (6.2%) <0.001 244 (14.0%) 176 (10.3%) <0.001 420 (12.2%)
Acceptance † 813 (77.7%) 1651 (68.6%) <0.001 1949 (69.7%) 510 (79.3%) <0.001 1156 (66.3%) 1308 (76.5%) <0.001 2464 (71.3%)
† Promoter
Self-protection 773 (95.1%) 1511 (91.5%) 0.001 1806 (92.7%) 473 (92.7%) 0.949 1068 (92.4%) 1216 (93.0%) 0.582 2284 (82.7%)
Patient Prot. 608 (74.8%) 1126 (68.2%) <0.001 1376 (70.6%) 354 (69.4%) 0.601 817 (70.7%) 917 (70.1%) 0.758 1734 (70.4%)
Family Prot. 690 (84.9%) 1354 (82.0%) 0.076 1626 (83.4%) 414 (81.2%) 0.229 996 (86.2%) 1048 (80.1%) <0.001 2044 (83.0%)
Community Prot. 618 (76.0%) 1018 (61.7%) <0.001 1256 (64.4%) 376 (73.7%) <0.001 788 (68.2%) 848 (64.8%) 0.080 1636 (66.4%)
Avoid Testing 238 (29.3%) 482 (29.2%) 0.967 561 (28.8%) 158 (31.0%) 0.332 344 (29.8%) 376 (28.7%) 0.582 720 (29.2%)
Easier Mobility 419 (51.5%) 809 (49.0%) 0.236 959 (49.2%) 267 (52.4%) 0.206 603 (52.2%) 625 (47.8%) 0.030 1128 (49.8%)
Employer 26 (3.2%) 58 (3.5%) 0.685 61 (3.1%) 23 (4.5%) 0.127 38 (3.3%) 46 (3.5%) 0.754 84 (3.4%)
Chi-squared test (χ2) had been used with a significance level (Sig.) ≤ 0.05. Prot. refers to protection. † COVID-19 Vaccine Booster Accepting-Group. The significant associations are in bold font.
Vaccines 2021, 9, 1437 12 of 29
The perceived safety was assessed using two items; (i) equal safety profile and (ii)
non-inferior safety (severe side effects). In total, 76.5% agreed that the current BDs are as
safe as the primer doses, while only 12.5% believe that the BD may impose more severe
side effects compared to the primer ones.
The perceived susceptibility was assessed using one item exploring the participants’
views of self-prioritization for BDs; 67.2% of the participants agreed to be prioritized to
receive the currently available BDs, and 78.1% believed that the benefits of BDs outweigh
their risks.
The moral dilemma of vaccine justice was evaluated on two levels; (i) globally and
(ii) nationally. Less than one-third (30.5%) of the participants disagreed with receiving the
BD after learning that administering third doses in developed economies may deprive
masses in the third world from getting even the first dose. More than one-third (37.6%)
of the participants disagreed with receiving the BD after learning that this may affect the
accessibility of some population groups to the vaccine (Table 5).
Table 5. Drivers of COVID-19 Vaccine-related Attitudes among Czech Healthcare Workers Responding to COVID-19
Vaccine BD Survey, November 2021 (n = 3454).
Variable Outcome Frequency (n) Percentage (%)
[Severe Illness] I think the currently available BD (third shots) can protect me
from severe COVID-19 infection.
Disagreement 309 8.9%
Not Sure 373 10.8%
Agreement 2772 80.3%
[Symptomatic Infection] I think the currently available BD (third shots) can
protect me from symptomatic COVID-19 infection.
Disagreement 663 19.2%
Not Sure 793 23.0%
Agreement 1998 57.8%
[Community Transmission] I think the currently available BD (third shots)
can prevent community transmission of SARS-CoV-2 and its variants.
Disagreement 645 18.7%
Not Sure 709 20.5%
Agreement 2100 60.8%
[Mutations Control] I will not take the third shoot (BD) until I find reliable
evidence confirming their ability to tackle the new circulating variants of
SARS-CoV-2.
Disagreement 589 17.1%
Not Sure 618 17.9%
Agreement 2247 65.1%
[Equal Safety] I think the currently available BD (third shots) are as safe as
the previous doses of COVID-19 vaccines.
Disagreement 241 7.0%
Not Sure 570 16.5%
Agreement 2643 76.5%
[Non-inferior Safety] I think that the currently available BD (third shots) are
as safe as the previous doses of COVID-19 vaccines.
Disagreement 1929 55.8%
Not Sure 1094 31.7%
Agreement 431 12.5%
[Risk-benefit Ratio] I believe that the benefits of BD (third shots) outweigh
their risks.
Disagreement 331 9.6%
Not Sure 426 12.3%
Agreement 2697 78.1%
[Self-prioritization] I agree to be prioritized to receive the currently available
BD (third shorts).
Disagreement 625 18.1%
Not Sure 509 14.7%
Agreement 2320 67.2%
[Global Vaccine Justice] I agree to receive the BD (third shot) of the
COVID-19 vaccine even after learning that administering third shots in
developed economies may deprive masses in the third world from getting
even the first dose.
Disagreement 1052 30.5%
Not Sure 1255 36.3%
Agreement 1147 33.2%
[National Vaccine Justice] I agree to receive the BD (third shot) of the
COVID-19 vaccine even after learning that this may affect the accessibility of
some population groups to the vaccine.
Disagreement 1297 37.6%
Not Sure 1153 33.4%
Agreement 1004 29.1%
[Vaccine Satisfaction] I think I should receive a different vaccine type/brand
for the BD from the previous doses.
Disagreement 1405 40.7%
Not Sure 1680 48.6%
Agreement † 369 10.7%
Vaccines 2021, 9, 1437 13 of 29
Table 5. Cont.
Variable Outcome Frequency (n) Percentage (%)
[Vaccine Selectivity] I think the government should purchase a particular
vaccine type/brand for the BD.
Disagreement 1071 31.0%
Not Sure 1644 47.6%
Agreement † 739 21.4%
† [Preferred Vaccine] Which vaccine type should be promoted for BD?
BTN162b2 611 69.3%
mRNA-1273 193 21.9%
AZD1222 21 2.4%
Ad26.COV2.S 57 6.5%
No missing data. † Agreement with “Vaccine Satsification” or “Vaccine Selectivity” statements.
Dissatisfaction with the primer doses type was reported by only 10.7% of the participants.
More than one-fifth (21.4%) of the participants were vaccine-selective as they agreed
that the government should purchase a certain vaccine type/brand for the BD, of which
BTN162b2 was the most commonly recommended type (69.3%), followed by mRNA-1273
(21.9%), Ad26.COV2.S (6.5%), and AZD1222 (2.4%).
MP had significantly (Sig. < 0.001, <0.001 and <0.001) higher agreement with the
BD capacity against severe illness, symptomatic infection, and community transmission
(85.7%, 63.7%, and 66.9%) compared to AHP (77.9%, 55.3%, and 58.2%), respectively. There
was no significant (Sig. = 0.808) difference between MP (64.8%) and AHP (65.2%) in terms
of agreement with the BD capacity against mutations. MP had significantly (Sig. < 0.001
and <0.001) higher agreement with the equal safety of BDs and higher disagreement with
the increased severity of BD side effects (84.5% and 65.8%) compared to AHP (73.0% and
51.5%), respectively.
MP had significantly (Sig. < 0.001, <0.001, and <0.001) higher agreement with the
BD capacity against severe illness, symptomatic infection, and community transmission
(85.7%, 63.7%, and 66.9%) compared to AHP (77.9%, 55.3%, and 58.2%), respectively. There
was no significant (Sig. = 0.808) difference between MP (64.8%) and AHP (65.2%) in terms
of agreement with the BD capacity against mutations. MP had significantly (Sig. < 0.001
and <0.001) higher agreement with the equal safety of BDs and higher disagreement with
the increased severity of BD side effects (84.5% and 65.8%) compared to AHP (73.0% and
51.5%), respectively.
Moreover, MP had significantly (Sig. < 0.001 and <0.001) higher levels of favourable
BD risk-benefit ratio and perceived susceptibility (84.1% and 72.6%) than AHP (75.4%
and 64.8%), respectively. Interestingly, MP had significantly (Sig. < 0.001 and <0.001)
lower levels of disagreement to receive BDs due to vaccine justice dilemmas globally and
nationally (23.3% and 31.5%) compared to AHP (33.6% and 40.2%), respectively. There was
no significant difference in terms of primer dose satisfaction or vaccine selectivity between
MP and AHP.
Males had significantly (Sig. < 0.001, <0.001, and =0.014) higher agreement with the
BD capacity against severe illness, symptomatic infection, and community transmission
(86.8%, 65.8%, and 65.2%) compared to females (78.9%, 56.3%, and 59.9%), respectively.
There was no significant (Sig. = 0.077) difference between males (62.1%) and females (65.7%)
in terms of agreement with the BD capacity against mutations. Males had significantly (Sig.
< 0.001 and <0.001) higher agreement with the equal safety of BD and higher disagreement
with the increased severity of BD side effects (85.8% and 70.5%) compared to females (74.6%
and 52.5%), respectively.
Additionally, males had significantly (Sig. < 0.001 and <0.001) higher levels of
favourable BD risk-benefit ratio and perceived susceptibility (85.4% and 72.8%) than
females (76.6% and 66.0%), respectively. Likewise, males had significantly (Sig. < 0.001 and
<0.001) lower levels of disagreement to receive BD due to vaccine justice dilemmas globally
and nationally (23.2% and 29.7%) compared to females (32.0% and 39.3%), respectively.
All the differences between the ≤47 year-old group and the >47 year-old group were not
statistically significant. Table 6.
Vaccines 2021, 9, 1437 14 of 29
Table 6. Drivers of COVID-19 Vaccine-related Attitudes among Czech Healthcare Workers Responding to COVID-19 Vaccine BD Survey Stratified by Profession, Gender, and Age Group,
November 2021 (n = 3454).
Variable Outcome
Medical
Professionals
(n = 1047)
Allied Health
Professionals
(n = 2407)
Sig.
Female
(n = 2796)
Male
(n = 643)
Sig.
≤47 Years
(n = 1744)
>47 Years
(n = 1710)
Sig.
Severe Illness
Disagree 78 (7.4%) 231 (9.6%) 0.042 261 (9.3%) 43 (6.7%) 0.033 194 (11.1%) 115 (6.7%) <0.001
Not Sure 72 (6.9%) 301 (12.5%) <0.001 329 (11.8%) 42 (6.5%) <0.001 210 (12.0%) 163 (9.5%) 0.018
Agree 897 (85.7%) 1875 (77.9%) <0.001 2206 (78.9%) 558 (86.8%) <0.001 1340 (76.8%) 1432 (83.7%) <0.001
Symptomatic
Infection
Disagree 196 (18.7%) 467 (19.4%) 0.640 548 (19.6%) 106 (16.5%) 0.070 397 (22.8%) 266 (15.6%) <0.001
Not Sure 184 (17.6%) 609 (25.3%) <0.001 675 (24.1%) 114 (17.7%) <0.001 415 (23.8%) 378 (22.1%) 0.238
Agree 667 (63.7%) 1331 (55.3%) <0.001 1573 (56.3%) 423 (65.8%) <0.001 932 (53.4%) 1066 (62.3%) <0.001
Community
Transmission
Disagree 178 (17.0%) 467 (19.4%) 0.096 521 (18.6%) 116 (18.0%) 0.727 400 (22.9%) 245 (14.3%) <0.001
Not Sure 169 (16.1%) 540 (22.4%) <0.001 599 (21.4%) 108 (16.8%) 0.009 366 (21.0%) 343 (20.1%) 0.500
Agree 700 (66.9%) 1400 (58.2%) <0.001 1676 (59.9%) 419 (65.2%) 0.014 978 (56.1%) 1122 (65.6%) <0.001
Mutations
Control
Disagree 217 (20.7%) 372 (15.5%) <0.001 443 (15.8%) 144 (22.4%) <0.001 329 (18.9%) 260 (15.2%) 0.004
Not Sure 152 (14.5%) 466 (19.4%) <0.001 515 (18.4%) 100 (15.6%) 0.087 320 (18.3%) 298 (17.4%) 0.480
Agree 678 (64.8%) 1569 (65.2%) 0.808 1838 (65.7%) 399 (62.1%) 0.077 1095 (62.8%) 1152 (67.4%) 0.005
Equal Safety
Disagree 68 (6.5%) 173 (7.2%) 0.463 203 (7.3%) 33 (5.1%) 0.054 145 (8.3%) 96 (5.6%) 0.002
Not Sure 94 (9.0%) 476 (19.8%) <0.001 508 (18.2%) 58 (9.0%) <0.001 311 (17.8%) 259 (15.1%) 0.033
Agree 885 (84.5%) 1758 (73.0%) <0.001 2085 (74.6%) 552 (85.8%) <0.001 1288 (73.9%) 1355 (79.2%) <0.001
Non-inferior
Safety
Disagree 689 (65.8%) 1240 (51.5%) <0.001 1467 (52.5%) 453 (70.5%) <0.001 956 (54.8%) 973 (56.9%) 0.217
Not Sure 242 (23.1%) 852 (35.4%) <0.001 955 (34.2%) 134 (20.8%) <0.001 555 (31.8%) 539 (31.5%) 0.848
Agree 116 (11.1%) 315 (13.1%) 0.101 374 (13.4%) 56 (8.7%) 0.001 233 (13.4%) 198 (11.6%) 0.113
Risk-benefit
Ratio
Disagree 86 (8.2%) 245 (10.2%) 0.071 272 (9.7%) 52 (8.1%) 0.199 198 (11.4%) 133 (7.8%) <0.001
Not Sure 80 (7.6%) 346 (14.4%) <0.001 383 (13.7%) 42 (6.5%) <0.001 248 (14.2%) 178 (10.4%) <0.001
Agree 881 (84.1%) 1816 (75.4%) <0.001 2141 (76.6%) 549 (85.4%) <0.001 1298 (74.4%) 1399 (81.8%) <0.001
Self-
prioritization
Disagree 142 (13.6%) 483 (20.1%) <0.001 537 (19.2%) 83 (12.9%) <0.001 387 (22.2%) 238 (13.9%) <0.001
Not Sure 145 (13.8%) 364 (15.1%) 0.332 414 (14.8%) 92 (14.3%) 0.747 291 (16.7%) 218 (12.7%) 0.001
Agree 760 (72.6%) 1560 (64.8%) <0.001 1845 (66.0%) 468 (72.8%) <0.001 1066 (61.1%) 1254 (73.3%) <0.001
Global Vaccine
Justice
Disagree 244 (23.3%) 808 (33.6%) <0.001 896 (32.0%) 149 (23.2%) <0.001 629 (36.1%) 423 (24.7%) <0.001
Not Sure 362 (34.6%) 893 (37.1%) 0.156 1058 (37.8%) 193 (30.0%) <0.001 596 (34.2%) 659 (38.5%) 0.008
Agree 441 (42.1%) 706 (29.3%) <0.001 842 (30.1%) 301 (46.8%) <0.001 519 (29.8%) 628 (36.7%) <0.001
Vaccines 2021, 9, 1437 15 of 29
Table 6. Cont.
Variable Outcome
Medical
Professionals
(n = 1047)
Allied Health
Professionals
(n = 2407)
Sig.
Female
(n = 2796)
Male
(n = 643)
Sig.
≤47 Years
(n = 1744)
>47 Years
(n = 1710)
Sig.
National Vaccine
Justice
Disagree 330 (31.5%) 967 (40.2%) <0.001 1099 (39.3%) 191 (29.7%) <0.001 766 (43.9%) 531 (31.1%) <0.001
Not Sure 323 (30.9%) 830 (34.5%) 0.037 961 (34.4%) 188 (29.2%) 0.013 513 (29.4%) 640 (37.4%) <0.001
Agree 394 (37.6%) 610 (25.3%) <0.001 736 (26.3%) 264 (41.1%) <0.001 465 (26.7%) 539 (31.5%) 0.002
Vaccine
Satisfaction
Disagree 393 (37.5%) 1012 (42.0%) 0.013 1151 (41.2%) 248 (38.6%) 0.227 764 (43.8%) 641 (37.5%) <0.001
Not Sure 531 (50.7%) 1149 (47.7%) 0.107 1370 (49.0%) 303 (47.1%) 0.391 786 (45.1%) 894 (52.3%) <0.001
Agree 123 (11.7%) 246 (10.2%) 0.182 275 (9.8%) 92 (14.3%) <0.001 194 (11.1%) 175 (10.2%) 0.397
Vaccine
Selectivity
Disagree 304 (29.0%) 767 (31.9%) 0.098 875 (31.3%) 190 (29.5%) 0.388 629 (36.1%) 442 (25.8%) <0.001
Not Sure 504 (48.1%) 1140 (47.4%) 0.675 1346 (48.1%) 292 (45.4%) 0.212 790 (45.3%) 854 (49.9%) 0.006
Agree 239 (22.8%) 500 (20.8%) 0.176 575 (20.6%) 161 (25.0%) 0.013 325 (18.6%) 414 (24.2%) <0.001
Preferred
Vaccine
BTN162b2 189 (66.3%) 422 (70.7%) 0.188 476 (70.0%) 132 (66.7%) 0.371 257 (63.9%) 354 (73.8%) 0.002
mRNA-1273 68 (23.9%) 125 (20.9%) 0.326 147 (21.6%) 45 (22.7%) 0.740 105 (26.1%) 88 (18.3%) 0.005
AZD1222 11 (3.9%) 10 (1.7%) 0.047 11 (1.6%) 10 (5.1%) 0.013 * 9 (2.2%) 12 (2.5%) 0.800
Ad26.COV2.S 17 (6.0%) 40 (6.7%) 0.678 46 (6.8%) 11 (5.6%) 0.543 31 (7.7%) 26 (5.4%) 0.167
Chi-squared test (χ2) and Fisher’s exact test (*) had been used with a significance level (Sig.) ≤ 0.05. The significant associations are in bold font.
Vaccines 2021, 9, 1437 16 of 29
3.6. Determinants of BD-Related Attitudes
All the demographic variables had impact on BD acceptance; male, non-pregnant
women, MP, and >47 year-old participants had significantly (Sig. < 0.001, <0.001, <0.001,
and <0.001) higher levels of BD acceptance (79.3%, 70.0%, 76.5%, and 77.7%) compared to
female, pregnant women, AHP, and ≤47 year-old participants (69.7%, 36.0%, 66.3%, and
68.6%), respectively.
While the previously infected participants (59.5%) had a significantly (Sig. < 0.001)
lower level of BD acceptance compared to their counterparts (76.9%), there was no significant
difference due to onset, clinical severity or most of the clinical manifestations.
Regarding the vaccine-related anamnesis, the previously vaccinated participants
(74.7%) had a significantly (Sig. < 0.001) higher level of BD acceptance compared to the
non-vaccinated participants (4.2%). BTN162b2 was the vaccine type associated with highest
level of BD acceptance (76.6%), while Ad26.COV2.S had the lowest level of BD acceptance
(27.3%). The participants who sought medical care following their primer dose (38.1%) had
a significantly (Sig. < 0.001) lower level of BD acceptance than their counterparts (76.1%).
The agreement with the BD capacity against severe illness, symptomatic infection, and
community transmission was significantly associated (Sig. < 0.001, <0.001, and <0.001) with
higher levels of BD acceptance (85.2%, 87.7%, and 88.4%) compared to the disagreement
with these constructs (11.0%, 39.2%, and 29.6%), respectively. Contrarily, the agreement
with the BD capacity against mutations (69.8%) was not significantly different from the
disagreement (74.9%). Moreover, the agreement with equal safety and the disagreement
with severer side effects were significantly associated (Sig. < 0.001 and <0.001) with BD
acceptance (83.2% and 84.3%) compared to the disagreement with equal safety and the
agreement with severer side effects (15.4% and 48.3%), respectively.
Likewise, the favourable risk-benefit ratio and agreement with perceived susceptibility
were significantly associated (Sig. < 0.001 and <0.001) with higher BD acceptance
(86.1% and 85.9%) compared to the unfavourable risk-benefit ratio and disagreement with
the perceived susceptibility (16.0% and 33.3%), respectively. The participants who were
affected by the ethical dilemmas of vaccine justice globally and nationally were significantly
associated (Sig. < 0.001 and <0.001) with decreased levels of BD acceptance (45.9% and
53.3%) compared to the participants who were not affected by the dilemmas (87.7% and
87.6%).
The primer dose satisfaction did not impact the BD acceptance, while the vaccine
selectively led to a non-significant increase in BD acceptance. The BD acceptance was the
highest in BTN162b2 as the preferred vaccine type (78.1%), and the lowest in the case of
Ad26.COV2.S (35.1%) (Table 7).
Table 7. Determinants of COVID-19 Vaccine-related Attitudes among Czech Healthcare Workers Responding to COVID-19
Vaccine BD Survey, November 2021 (n = 3454).
Variable Outcome
Rejection
(n = 570; 16.5%)
Sig.
Hesitancy
(n = 420; 12.2%)
Sig.
Acceptance
(n = 2464; 71.3%)
Sig.
Demographic
Gender
Female † 468 (16.7%) 0.159 379 (13.6%) <0.001 1949 (69.7%) <0.001
Male 93 (14.5%) 40 (6.2%) 510 (79.3%)
†
Pregnancy
Yes 12 (48.0%) <0.001 4 (16.0%) 0.720 9 (36.0%) <0.001
No 456 (16.5%) 375 (13.5%) 1940 (70.0%)
Age Group
≤47 years-old 344 (19.7%) <0.001 244 (14.0%) <0.001 1156 (66.3%) <0.001
>47 years-old 226 (13.2%) 176 (10.3%) 1308 (76.5%)
Profession
Medical
Professionals
154 (14.7%) 0.061 80 (7.6%) <0.001 813 (77.7%) <0.001
Allied Health
Professionals
416 (17.3%) 340 (14.1%) 1651 (68.6%)
Vaccines 2021, 9, 1437 17 of 29
Table 7. Cont.
Variable Outcome
Rejection
(n = 570; 16.5%)
Sig.
Hesitancy
(n = 420; 12.2%)
Sig.
Acceptance
(n = 2464; 71.3%)
Sig.
COVID-19-relatedAnamnesis
Infection
Yes ‡ 268 (24.2%) <0.001 180 (16.3%) <0.001 658 (59.5%) <0.001
No 302 (12.9%) 240 (10.2%) 1806 (76.9%)
‡ Onset
Before 1st Dose 247 (25.4%) 0.012 155 (16.0%) 0.451 569 (58.6%) 0.104
Between Doses 9 (13.0%) 0.025 16 (23.2%) 0.108 44 (63.8%) 0.455
After 2nd Dose 12 (18.2%) 0.237 9 (13.6%) 0.549 45 (68.2%) 0.138
‡ Severity
Asymptomatic 19 (24.1%) 0.969 9 (11.4%) 0.222 51 (64.6%) 0.341
Mild 163 (24.8%) 0.611 106 (16.1%) 0.857 389 (59.1%) 0.758
Moderate 81 (23.3%) 0.641 63 (18.2%) 0.252 203 (58.5%) 0.649
Severe 3 (16.7%) 0.586 * 2 (11.1%) 0.753 * 13 (72.2%) 0.267
Critical 2 (50.0%) 0.249 * 0 (0%) 1.000 * 2 (50.0%) 1.000 *
‡ Signs &
Symptoms
Fever 153 (24.5%) 0.799 94 (15.1%) 0.215 377 (60.4%) 0.477
Cough 133 (24.1%) 0.915 96 (17.4%) 0.315 323 (58.5%) 0.508
Dyspnea 73 (22.8%) 0.482 53 (16.6%) 0.869 194 (60.6%) 0.625
Fatigue 210 (24.6%) 0.581 155 (18.2%) 0.002 488 (57.2%) 0.004
Myalgia 175 (23.9%) 0.725 127 (17.3%) 0.175 430 (58.7%) 0.477
Headache 176 (25.1%) 0.353 128 (18.3%) 0.017 396 (56.6%) 0.009
Anosmia 170 (25.6%) 0.181 120 (18.1%) 0.044 373 (56.3%) 0.007
Dysgeusia 129 (25.2%) 0.466 97 (19.0%) 0.024 285 (55.8%) 0.019
Pharyngitis 56 (27.7%) 0.200 33 (16.3%) 0.979 113 (55.9%) 0.255
Congestion 99 (27.1%) 0.115 73 (20.0%) 0.019 193 (52.9%) 0.002
Rhinitis 102 (28.7%) 0.018 67 (18.8%) 0.114 187 (52.5%) 0.001
Nausea 36 (22.9%) 0.681 26 (16.6%) 0.917 95 (60.5%) 0.780
Vomiting 10 (18.2%) 0.283 13 (23.6%) 0.129 32 (58.2%) 0.839
Diarrhea 43 (21.0%) 0.228 41 (20.0%) 0.109 121 (59.0%) 0.879
Vaccine-relatedAnamnesis
Vaccinated
Yes Ψ 422 (12.8%) <0.001 408 (12.4%) 0.044 2457 (74.7%) <0.001
No 148 (88.6%) 12 (7.2%) 7 (4.2%)
Ψ Vaccine
Type
BTN162b2 349 (11.7%) <0.001 349 (11.7%) <0.001 2282 (76.6%) <0.001
mRNA-1273 35 (20.0%) 0.004 44 (25.1%) <0.001 96 (54.9%) <0.001
AZD1222 11 (12.5%) 0.923 10 (11.4%) 0.762 67 (76.1%) 0.761
Ad26.COV2.S 27 (61.4%) <0.001 5 (11.4%) 0.823 12 (27.3%) <0.001
Ψ Doses
Number
One 29 (49.2%) <0.001 13 (22.0%) 0.024 17 (28.8%) <0.001
Two 291 (17.8%) <0.001 366 (22.4%) <0.001 976 (59.8%) <0.001
Three 102 (6.4%) <0.001 29 (1.8%) <0.001 1464 (91.8%) <0.001
Ψ Medical
Care
Yes 48 (42.5%) <0.001 22 (19.5%) 0.021 43 (38.1%) <0.001
No 374 (11.8%) 386 (12.2%) 2414 (76.1%)
Severe
Illness
Disagree 246 (79.6%) <0.001 29 (9.4%) 0.118 34 (11.0%) <0.001
Not Sure 111 (29.8%) <0.001 193 (51.7%) <0.001 69 (18.5%) <0.001
Agree 213 (7.7%) <0.001 198 (7.1%) <0.001 2361 (85.2%) <0.001
Symptomatic
Infection
Disagree 302 (45.6%) <0.001 101 (15.2%) 0.007 260 (39.2%) <0.001
Not Sure 129 (16.3%) 0.839 213 (26.9%) <0.001 451 (56.9%) <0.001
Agree 139 (7.0%) <0.001 106 (5.3%) <0.001 1753 (87.7%) <0.001
Community
Transmis-
sion
Disagree 330 (51.2%) <0.001 124 (19.2%) <0.001 191 (29.6%) <0.001
Not Sure 102 (14.4%) 0.089 190 (26.8%) <0.001 417 (58.8%) <0.001
Agree 138 (6.6%) <0.001 106 (5.0%) <0.001 1856 (88.4%) <0.001
Mutations
Control
Disagree 111 (18.8%) 0.093 37 (6.3%) <0.001 441 (74.9%) 0.037
Not Sure 77 (12.5%) 0.003 87 (14.1%) 0.107 454 (73.5%) 0.197
Agree 382 (17.0%) 0.282 296 (13.2%) 0.013 1569 (69.8%) 0.007
Equal
Safety
Disagree 179 (74.3%) <0.001 25 (10.4%) 0.379 37 (15.4%) <0.001
Not Sure 166 (29.1%) <0.001 175 (30.7%) <0.001 229 (40.2%) <0.001
Agree 225 (8.5%) <0.001 220 (8.3%) <0.001 2198 (83.2%) <0.001
Vaccines 2021, 9, 1437 18 of 29
Table 7. Cont.
PsychosocialDriversofCOVID-19VaccineBD-relatedAttitudes
Variable Outcome
Rejection
(n = 570; 16.5%)
Sig.
Hesitancy
(n = 420; 12.2%)
Sig.
Acceptance
(n = 2464; 71.3%)
Sig.
Non-
inferior
Safety
Disagree 184 (9.5%) <0.001 118 (6.1%) <0.001 1627 (84.3%) <0.001
Not Sure 232 (21.2%) <0.001 233 (21.3%) <0.001 629 (57.5%) <0.001
Agree 154 (35.7%) <0.001 69 (16.0%) 0.009 208 (48.3%) <0.001
Risk-
benefit
Ratio
Disagree 251 (75.8%) <0.001 27 (8.2%) 0.019 53 (16.0%) <0.001
Not Sure 130 (30.5%) <0.001 206 (48.4%) <0.001 90 (21.1%) <0.001
Agree 189 (7.0%) <0.001 187 (6.9%) <0.001 2321 (86.1%) <0.001
Self-
prioritization
Disagree 298 (47.7%) <0.001 119 (19.0%) <0.001 208 (33.3%) <0.001
Not Sure 99 (19.4%) 0.052 146 (28.7%) <0.001 264 (51.9%) <0.001
Agree 173 (7.5%) <0.001 155 (6.7%) <0.001 1992 (85.9%) <0.001
Global
Vaccine
Justice
Disagree 360 (34.2%) <0.001 209 (19.9%) <0.001 483 (45.9%) <0.001
Not Sure 123 (9.8%) <0.001 157 (12.5%) 0.634 975 (77.7%) <0.001
Agree 87 (7.6%) <0.001 54 (4.7%) <0.001 1006 (87.7%) <0.001
National
Vaccine
Justice
Disagree 374 (28.8%) <0.001 232 (17.9%) <0.001 691 (53.3%) <0.001
Not Sure 124 (10.8%) <0.001 136 (11.8%) 0.643 893 (77.5%) <0.001
Agree 72 (7.2%) <0.001 52 (5.2%) <0.001 880 (87.6%) <0.001
Vaccine
Satisfaction
Disagree 227 (16.2%) 0.650 158 (11.2%) 0.173 1020 (72.6%) 0.175
Not Sure 278 (16.5%) 0.945 212 (12.6%) 0.422 1190 (70.8%) 0.524
Agree 65 (17.6%) 0.542 50 (13.6%) 0.387 254 (68.8%) 0.261
Vaccine
Selectivity
Disagree 220 (20.5%) <0.001 130 (12.1%) 0.979 721 (67.3%) <0.001
Not Sure 255 (15.5%) 0.135 203 (12.3%) 0.747 1186 (72.1%) 0.320
Agree 95 (12.9%) 0.003 87 (11.8%) 0.716 557 (75.4%) 0.006
Preferred
Vaccine
BTN162b2 69 (11.3%) <0.001 65 (10.6%) 0.255 477 (78.1%) <0.001
mRNA-1273 22 (11.4%) 0.248 24 (12.4%) 0.627 147 (76.2%) 0.573
AZD1222 5 (23.8%) 0.187 2 (9.5%) 0.779 14 (66.7%) 0.398
Ad26.COV2.S 27 (47.4%) <0.001 10 (17.5%) 0.135 20 (35.1%) <0.001
Chi-squared test (χ2) and Fisher’s exact test (*) had been used with a significance level (Sig.) ≤ 0.05. † Female participants. ‡ Pregnant
participants. The significant associations are in bold font.
3.7. Analysis of COVID-19 Vaccine BD Hesitancy vs. Acceptance
Univariate logistic regression was performed to estimate the odds ratio (OR) of BD
hesitancy and BD acceptance across the significant demographic and anamnestic predictors.
Female participants were 2.36 (CI 95%: 1.69–3.31) times more likely to be BD-hesitant than
males, and pregnant women were also 1.22 (CI 95%: 0.42–3.57) more likely to be hesitant
compared to non-pregnant women. The young age group, AHP, the previously infected
participants, the previously non-vaccinated participants, and the participants who sought
medical care were 1.42 (CI 95%: 1.15–1.74), 1.99 (CI 95%: 1.54–2.57), 1.71 (CI 95%: 1.39–2.10),
1.83 (CI 95%: 1.01–3.32), and 1.75 (CI 95%: 1.08–2.82) times more likely to be hesitant
compared to their counterparts.
Contrarily, male participants were 1.67 (CI 95%: 1.36–2.05) times more likely to be BDaccepting
than females, and non-pregnant women were also 4.15 (CI 95%: 1.83–9.43) more
likely to accept BD compared to pregnant women. The old age group, MP, the previously
non-infected participants, the previously vaccinated participants, and the participants who
did not seek medical care were 1.66 (CI 95%: 1.43–1.92), 1.59 (CI 95%: 1.34–1.88), 2.27
(CI 95%: 1.95–2.65), 67.66 (CI 95%: 31.62–144.81), and 5.17 (CI 95%: 3.51–7.63) times more
likely to accept BDs than their counterparts (Table 8).
Vaccines 2021, 9, 1437 19 of 29
Table 8. Regression Analysis of COVID-19 Vaccine Hesitancy vs. Acceptance Demographic and Anamnestic Determinants among Czech Healthcare Workers Responding to COVID-19
Vaccine BD Survey, November 2021 (n = 3454).
Hesitancy Acceptance
Predictor B (SE) Wald OR (CI 95%) Sig. Predictor B (SE) Wald OR (CI 95%) Sig.
Female (vs. Male) 0.86 (0.17) 24.91 2.36 (1.69–3.31) <0.001 Male (vs. Female) 0.51 (0.11) 23.34 1.67 (1.36–2.05) <0.001
Pregnancy: Yes (vs. No) 0.20 (0.55) 0.13 1.22 (0.42–3.57) 0.720 Pregnancy: No (vs. Yes) 1.42 (0.42) 11.55 4.15 (1.83–9.43) <0.001
≤47 yo (vs. >47 yo) 0.35 (0.11) 10.98 1.42 (1.15–1.74) <0.001 >47 yo (vs. ≤47 yo) 0.50 (0.08) 43.63 1.66 (1.43–1.92) <0.001
AHP (vs. Medical) 0.69 (0.13) 27.85 1.99 (1.54–2.57) <0.001 Medical (vs. AHP) 0.46 (0.09) 29.01 1.59 (1.34–1.88) <0.001
Infection: Yes (vs. No) 0.54 (0.11) 25.38 1.71 (1.39–2.10) <0.001 Infection: No (vs. Yes) 0.82 (0.08) 109.11 2.27 (1.95–2.65) <0.001
Vaccinated: No (vs. Yes) 0.61 (0.30) 3.95 1.83 (1.01–3.32) 0.047 Vaccinated: Yes (vs. No) 4.22 (0.39) 228.85 67.66 (31.62–144.81) <0.001
Care: Yes (vs. No) 0.56 (0.24) 5.23 1.75 (1.08–2.82) 0.022 Care: No (vs. Yes) 1.64 (0.20) 68.74 5.17 (3.51–7.63) <0.001
Binary logistic regression had been used with a significance level (Sig.) ≤ 0.05. AHP refers to Allied Health Professionals. The significant associations are in bold font.
Vaccines 2021, 9, 1437 20 of 29
Multivariate logistic regression was performed to estimate the adjusted odds ratio
(AOR) of BD acceptance across the various psychosocial predictors while controlling for
the significant demographic and anamnestic drivers. The agreement with controlling of
severe illness, symptomatic infection, and community transmission was associated with an
AOR of 25.55 (CI 95%: 19.45–33.57), 5.81 (CI 95%: 4.78–7.07), and 7.90 (CI 95%: 6.47–9.65)
times more likely to be BD-accepting compared to their counterparts, respectively.
The disagreement with controlling mutations and severer side effects was associated
with AOR of 1.31 (CI 95%: 1.01–1.69) and 3.97 (CI 95%: 3.28–4.81) times more likely to
accept BDs, respectively. The favourable risk-benefit ratio and the perceived susceptibility
increased the AOR of BD acceptance with 19.42 (CI 95%: 15.20–24.80) and 7.10 (CI 95%: 5.83–
8.63) times, respectively. Being influenced by the ethical dilemma of vaccine justice both
globally 0.23 (CI 95%: 0.19–0.28) and nationally 0.32 (CI 95%: 0.27–0.39) was associated with
a decreased AOR of BD acceptance. Vaccine satisfaction and selectivity had no significant
impact on BD acceptance (Table 9).
Table 9. Regression Analysis of COVID-19 Vaccine Acceptance Psychosocial Determinants among
Czech Healthcare Workers Responding to COVID-19 Vaccine BD Survey, November 2021 (n = 3454).
Predictor B (SE) Wald AOR (CI 95%) Sig.
Severe Illness: Agree 3.24 (0.14) 542.23 25.55 (19.45–33.57) <0.001
Symptomatic Infection: Agree 1.76 (0.10) 310.51 5.81 (4.78–7.07) <0.001
Community Transmission: Agree 2.07 (0.10) 410.49 7.90 (6.47–9.65) <0.001
Mutations Control: Disagree 0.27 (0.13) 4.21 1.31 (1.01–1.69) 0.040
Equal Safety: Agree 1.99 (0.11) 350.53 7.32 (5.94–9.01) <0.001
Non-inferior Safety: Disagree 1.38 (0.10) 198.93 3.97 (3.28–4.81) <0.001
Risk-benefit Ratio: Agree 2.97 (0.13) 565.22 19.42 (15.20–24.80) <0.001
Self-prioritization: Agree 1.96 (0.10) 383.86 7.10 (5.83–8.63) <0.001
Global Vaccine Justice: Disagree −1.46 (0.10) 226.91 0.23 (0.19–0.28) <0.001
National Vaccine Justice: Disagree −1.14 (0.09) 146.96 0.32 (0.27–0.39) <0.001
Vaccine Satisfaction: Agree 0.06 (0.16) 0.16 1.06 (0.78–1.44) 0.689
Vaccine Selectivity: Agree 0.14 (0.11) 1.49 1.15 (0.92–1.44) 0.223
Binary logistic regression had been used with a significance level (Sig.) ≤ 0.05 and adjusted for gender, pregnancy,
age, profession, COVID-19 infection and vaccination, and seeking medical care. The significant associations are in
bold font.
4. Discussion
This study revealed that a high proportion (71.3%) of the Czech HCW favour the
COVID-19 vaccine BD, while 12.2% are still hesitant and 16.6% are against the currently
available BD. These results are consistent with what had been recently reported by Rzymski
et al. 2021, who found that 71% of the Polish adult population declared their willingness to
receive a COVID-19 vaccine BD, while the rest were not in favour of BDs [23]. In Japan,
Sugawara et al. 2021 revealed that 89.1% of Japanese medical students were willing to
receive the hypothetical BDs of COVID-19 vaccines [85].
The target population of this study was Czech HCW; therefore, the harvested sample
was intended to be as representative as possible for the target population. According to
a recent report of the Czech Statistical Office (CZSO), around 21.9% of the HCW in the
Czech Republic were males, while the vast majority (78.1%) were females in 2019 [86]. Our
sample reflected this gender distribution, as 18.6% were males and 80.9% were females.
The mean age of Czech HCW according to the CZSO report of 2017 was 46.1 years old, thus
corresponding with the mean age of our harvested sample (46.97 ± 11.78) [87]. Regarding
the health professions’ categories, the latest report of IHIS-CR revealed that about 20.9%
were MP and 79.1% were AHP; therefore, MP was over-represented in our sample (30.3%)
compared to AHP (69.7%) [67].
Less than one-third (32%) of our participants had reported being infected by SARSCoV-2
in the previous time. Until 10 November 2021, 1.8 million accumulated cases
of COVID-19 were reported in the Czech Republic, representing 17.2% of the general
population, thus making the proportion of infected participants higher than the average
Vaccines 2021, 9, 1437 21 of 29
population [88]. According to Jarkovsky et al. 2021, around 6.2% of the confirmed COVID-
19 patients during the first wave in the Czech Republic were suffering from a severe clinical
form of the disease [89]. The proportion of the severe and critical cases in our sample was
2% lower than the reported proportion of accumulated hospitalized cases in the Czech
Republic (≈ 7.7%) [90,91]. The vast majority of COVID-19 infection cases occurred before
receiving the first dose (87.8%), and the rest occurred after the first dose (6.2%) and after the
second dose (6%). Frontline HCW are amongst the high risk groups for COVID-19 infection;
therefore, they were recommended to follow strict infection control measures for which
they exhibited high levels of compliance in multiple locations where the transmission
levels were lowered significantly [92–94]. Nevertheless, COVID-19 infections among HCW
had been frequently reported both before and after the vaccine rollout with a clear and
sustained decline in cases number after mass vaccination [95]. This finding confirms the
substantial pooled effectiveness of the approved vaccines in the Czech Republic and the
European Union, and it is in agreement with the previous findings of rapid decline in
both asymptomatic and symptomatic COVID-19 infections among HCW following vaccine
rollout in California [95,96].
Most participants (95.2%) reported being vaccinated against SARS-CoV-2, while 167
declared that they were not vaccinated at all. Gilboa et al. 2021 found that up to 97.1%
of the surveyed HCW in Israel were willing to be vaccinated, while the most common
reason for noncompliance with COVID-19 vaccination was pregnancy [97]. However,
devastating inequalities between MP and AHP were reported at the beginning of the
COVID-19 vaccine rollout; for instance, in the US, 75.1% of MP were vaccinated and only
45.6% of the AHP by March 2021; the difference was minor between our participating
MP (96.7%) and AHP (94.5%) [98]. Moreover, the higher vaccine uptake rate among male
and older participants may confirm what had been previously reported by the COVID-19
vaccine hesitancy studies that attempted to predict the drivers of COVID-19 VH and found
that female gender and women of a young age can be determinants of lower vaccine
acceptance [68,99,100]. The most commonly administered vaccine among our sample
was BTN162b2 (90.7%), which was higher than its proportion among the general Czech
population (82.7%) as of 15 November 2021 [101]. The second most common vaccine was
mRNA-1273 (5.3%), followed by AZD1222 (2.7%) and Ad26.COV2.S (1.3%), and this exact
order was found among the general population: 7.8%, 6.9%, and 2.6%, respectively [101].
Our participants’ most cited reason for accepting BD was family protection (83%),
followed by self-protection (82.7%). Rutten et al. 2021 laid down a list of evidence-based
strategies for addressing COVID-19 VH by clinical organizations, and one of those strategies
was to focus on vaccines as an essential tool to protect one’s own and family health [102].
In a large survey-based study of hospital employees in the United States, the most common
reason for accepting COVID-19 vaccination was family protection (86.7%), followed by
self-protection (82.9%) [103]. Another recent study in Austria found that self-protection
(60.3%) and family protection (55.3%) were the most common reasons for compliance with
the COVID-19 guidelines; the investigators concluded that community health protection
was also a significant altruistic reason for compliance [104]. The third most cited reason for
accepting BD was patient protection (70.4%) which was even higher than community health
protection (66.4%). One of the solid arguments for mandating COVID-19 vaccination of
HCW is patient protection, thus aiming to fulfil the “do no harm” rule through continuing
to provide care for all patients, including COVID-19 patients [105]. On comparing the
high level of altruistic reasons for BD acceptance, e.g., family protection (82.7%), patient
protection (70.4%), and community health protection (66.4%), to the extremely low level
of the non-altruistic reasons, e.g., employer endorsement (3.4%), it becomes more evident
that the recommendations of Gur-Arie et al., 2021 of implementing policies strengthening
the HCW trust in vaccines and health systems should be the first step before proceeding to
consider vaccination mandates [105].
The perceived effectiveness of COVID-19 vaccine BD was a significant and robust
predictor of BD acceptance among our participants. The capacity to prevent severe illness,
Vaccines 2021, 9, 1437 22 of 29
symptomatic infection, and community transmission was associated with an increased
AOR of BD acceptance: 25.55, 5.81, and 7.90 times, respectively. The current body of
evidence confirms the beliefs of Czech HCW who agreed that COVID-19 BD had capacity
against infection-related outcomes; as the 7-day effectiveness of BDs was found to be
93% in reduction of hospitalization, 92% for severe illness, and 81% for COVID-19-related
mortality when compared to the recipients of two doses five months ago [106]. Moreover,
the adjusted rate ratio (ARR) of symptomatic infection was 11.3 times among the nonbooster
group vs. the booster group; likewise, the ARR of severe illness was 19.5 times
among the non-booster group [40]. Presently, evidence is still lacking and required to
verify the capacity of BD against community spread of COVID-19 infection, which might
explain why the belief of BD capacity against mutations was not a potent predictor of BD
acceptance in our sample.
The perceived safety of COVID-19 vaccine BDs was another significant and strong
predictor of BD acceptance. While the assuring evidence on BD side effects is still preliminary
and predominantly coming from non-peer-reviewed sources, our participants were
inclined to believe that the BDs will have a similar safety profile of the primer doses (79.2%)
and no more-severe side effects will emerge following BDs (56.9%). The male participants
had higher levels of BD perceived safety compared to their female counterparts; therefore,
the gender-based differences of the self-reported side effects following the primer doses
could be hypothesized as one of the obstacles for females to accept BD as they were more
likely bothered by the post-vaccination side effects [24,43,107,108]. It is yet unclear and
requires further investigation why the MP may have higher BD perceived safety levels
than the AHP. Gadoth et al., 2021 found that nurses were four times more likely to delay
COVID-19 vaccination compared to physicians. Given that this finding was frequently
reported with the influenza vaccine, the public health authorities were called upon to take
this issue seriously because nurses are more involved in administering vaccines and are
placed at the front line with patients [109–112].
The participants in the ethical conflict of accepting COVID-19 vaccine BDs while
millions of people are still unvaccinated worldwide significantly lower odds of BD acceptance.
On 12 November 2021, the WHO Director-General described the rollout of BDs
in high-income countries (HIC) as a scandalous event [113]. “It makes no sense to give
boosters to healthy adults, or to vaccinate children, when health workers, older people and
other high-risk groups around the world are still waiting for their first dose”, Dr. Tedros
Adhanom Ghebreyesus said [113]. One of the suggested approaches to achieve global
vaccine equity is to donate excess doses to low- and middle-income countries (LMIC) by
HIC through the COVAX platform, and such an approach can protect both LMIC and
HIC [114]. Until 15 November 2021, the WHO-SAGE position from COVID-19 vaccine BD
is not in favour of re-vaccinating HCW or the general healthy population, but it is also
noteworthy that this recommendation will be re-evaluated in December 2021 [115].
The favourable risk-benefit ratio estimation was a significant and robust predictor
of BD acceptance among our participants. The same finding was reported earlier among
several population groups, e.g., Czech university students [70], Palestinian healthcare
students [71], and American HCW [116], who were more likely to accept COVID-19 vaccine
when they had favourable risk-benefit ratio assessment. This fundamental concept of an
individual’s risk-benefit ratio assessment has been widely used in vaccine communication
and vaccine hesitancy research, as it portrays perceived effectiveness and safety of the
vaccine from one side and perceived susceptibility to the infection from another side [117].
Rey et al. 2018 used the risk-benefit balance (RBB) to evaluate VH among French parents,
and it was proven as an effective method for explaining the VH of human papillomavirus,
hepatitis B virus, measles, and seasonal influenza vaccines [117].
4.1. Strengths
To the best of the authors’ knowledge, this is the first study to evaluate the attitudes
of the Czech population towards COVID-19 vaccine BD, and what is more important than
Vaccines 2021, 9, 1437 23 of 29
estimating the general prevalence of BD acceptance is exploring the potential demographic
and anamnestic determinants and the psychosocial drivers of VBH. This study used an
anonymous online SAQ that aimed to give the respondents room to express their views
towards vaccines without restrictions or feeling judged; therefore, we believe that the
Hawthorne bias had been controlled in this design. Third, the harvested sample has an
optimal size and decent representativeness, so it reflects several essential characteristics of
the target population, e.g., mean age, gender distribution, and professional groups. Finally,
the current study shed light on the COVID-19 infection rate, clinical severity stratification,
and vaccination rate among Czech HCW.
4.2. Limitations
This study was limited by a number of factors, including (a) lack of information about
the administered vaccine type of each dose; (b) lack of information on participants’ general
medical anamnesis and BMI; (c) an insufficient number of pregnant women, LGBTQ+, and
other minority groups; and (d) insufficient information on the post-vaccination experience
of the participants, especially the side-effects of primer doses.
4.3. Implications
The results of this study imply that future research on COVID-19 VBH should explore
the role of gender and age on VBH across different population groups. Our study
also suggests that public health communication regarding COVID-19 BDs should benefit
from the following approaches: (a) highlighting and emphasizing the evidence on BD
effectiveness against severe illness, symptomatic infection, and community transmission;
(b) highlighting and emphasizing the evidence on BD equal safety with the primer doses;
(c) addressing the potential ethical conflicts especially those related vaccine justice; and
(d) focusing on alteration of the individual’s risk-benefit ratio of BDs to become more
favourable, especially among frontline HCW, e.g., nurses. Using altruistic motivators to
induce vaccine uptake among HCW should be prioritized over mandating the vaccines.
5. Conclusions
Within the limitations of this study, a high level of BD acceptance (71.3%) was found
among Czech HCW, while 12.2% were still hesitant and 16.6% were against the currently
available BDs. These results are consistent with other recent results from central Europe.
Medical professionals and male and older participants were more likely to accept BDs
rather than allied health professionals and female and younger participants. The BDs’
perceived effectiveness against severe illness, symptomatic infection, and community
transmission was found to be a significant and robust predictor for BD acceptance, while
the effectiveness against the circulating variants was not that important for our target
population. The BDs’ perceived safety and ethical dilemmas of vaccine justice should
be addressed sufficiently while communicating with HCW and other population groups.
The altruistic reasons for BD acceptance, i.e., family protection, patient protection, and
community health protection, underpin the recommendation of postponing the COVID-
19 vaccine mandating in favour of stressing these altruistic concerns amid public health
messaging.
Supplementary Materials: The following are available online at https://www.mdpi.com/article/
10.3390/vaccines9121437/s1, Figure S1. The sample size of healthcare workers in Czech Republic—
Epi-InfoTM version 7.2.4. Table S1. The results of test re-test reliability. Table S2. Demographic
Characteristics of Czech Healthcare Workers Responding to COVID-19 Vaccine BD Survey, November
2021 (n = 3454).
Author Contributions: Conceptualization, M.K. and A.R.; methodology, M.K., A.R. and A.P.; software,
A.R.; validation, M.K.; formal analysis, A.R.; investigation, A.P. and M.K.; writing—original
draft preparation, A.R. and L.M.; writing—review and editing, A.P. and M.K.; supervision, M.K.;
Vaccines 2021, 9, 1437 24 of 29
project administration, A.R.; funding acquisition, M.K. and A.R. All authors have read and agreed to
the published version of the manuscript.
Funding: This study was funded by Masaryk University, grant number MUNI/IGA/1543/2020 and
MUNI/A/1608/2020. The work of M.K., A.R. and A.P. was supported by the INTER-EXCELLENCE
grant number LTC20031—“Towards an International Network for Evidence-based Research in
Clinical Health Research in the Czech Republic”.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki and approved by the Ethics Committee of the Faculty of Medicine, Masaryk
University Ref. 63/2021 on 19 October 2021.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data that support the findings of this study are available from the
corresponding author upon reasonable request.
Acknowledgments: This work is dedicated to the more than thirty thousand fatalities and their
families who have fallen victim to COVID-19 in Czechia. The authors would like to thank all the
anonymous participants due to their time and effort in sharing their booster doses-related views
during this critical time. Also, we would like to thank Jitka Klugarová and Michal Košˇcík, members
of Czech National Centre for Evidence-Based Healthcare and Knowledge Translation, members of
Department of Quality of Healthcare, Institute for health information and statistics, and Head Nurse
of the Ministry of Health of the Czech Republic Alice Sntrnadová, MBA for their help in validating
and promoting the survey. We thank the Chairs of professional medical associations in the Czech
Republic, who disseminated the SAQ to their members.
Conflicts of Interest: The authors declare no conflict of interest.
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