Willingness of Healthcare Workers to Recommend or Receive a Third COVID-19 Vaccine Dose: A Cross-Sectional Study from Jordan

Round 1

Reviewer 1 Report (Previous Reviewer 3)

The authors responded exhaustively to the clarifications requested and the article can be considerated for publication

Author Response

Reply to the Reviewers

Dear Doctor

Kindly see the followings response to your important notes regarding our manuscript.

Regards

Mohammad

 

Reviewer 1:

Thank you, we appreciate your efforts. We are pleased that we considered all your comments and responded as you expected.

 

Sincerely yours

Mohammad

 

Reviewer 2 Report (New Reviewer)

This cross-sectional study investigates the willingness of healthcare workers in Jordan to receive and recommend COVID-19 vaccines. It asked important questions and gathered impressive information. But it has some flaws, as explained below.

- The introduction contains factual errors. As an example, the first two sentences mention that the pandemic was declared in March 2021 and vaccines became available late 2021. These should both say 2020, not 2021.

- The methods are well-described, but not suited to the research question. Usually, studies like this would calculate an Odds Ratio (OR). I've never seen one use the Chi-squared test. This test compares observations to expectations, which is not relevant to this study.

- It is unclear why some hospitals were selected. Was every healthcare worker in these hospitals contacted? If not, who was selected and how did that happen? Explain the random collection of phone numbers.

- The discussion must include a comparison of this study and reference 41 (authored by Lataifeh and colleagues). They look very similar. Additional context is needed.

- The first two paragraphs in the discussion have many in-text citations which see incorrect. For example, lines 24 and 25 mention a study on Arab HCWs but cites a study done in Germany. This article makes no mention of Arab or Jordanian workers specifically.

Author Response

Reply to the Reviewers

 

Dear Doctor

Kindly see the followings response to your important notes regarding our manuscript.

Regards

Mohammad

 

Reviewer 2:

 

- The introduction contains factual errors. As an example, the first two sentences mention that the pandemic was declared in March 2021 and vaccines became available late 2021. These should both say 2020, not 2021.

Thank you, we changed both to 2020 (see the introduction)

- The methods are well-described, but not suited to the research question. Usually, studies like this would calculate an Odds Ratio (OR). I've never seen one use the Chi-squared test. This test compares observations to expectations, which is not relevant to this study.

We understand the reviewer concerns regarding the selection of the test; and we thank him/her for happiness with the methodology. Usually the researcher have choices to use  chi-square, T-Test and ANOVA (Analysis of Variance) tests, which can be used to examine the relationship between background characteristics (e.g. age, gender, education level, occupation) and the willingness of healthcare workers (HCWs) to recommend the third dose of the COVID-19 vaccine to their patients.

We consult the chi-square distribution table to determine the critical value for the significance level we have chosen and the degrees of freedom. Based on the calculated chi-square value we determine the significant association between the background characteristics and the willingness of HCWs to recommend the vaccine. The odds ratio or the contingency table examination used usually to calculate the effect size which we do not aim to do here.

 

 

- It is unclear why some hospitals were selected. Was every healthcare worker in these hospitals contacted? If not, who was selected and how did that happen? Explain the random collection of phone numbers.

Thank you, this is important point. We added the following in page 3):

The four hospitals selected because they responded to our invitation which sent to all central hospitals with large number of HCWs when compared to others. We started the recruitment when we found them represent the three regions of Jordan. We contacted the human resource department to send the invitation to all  HCWs within the hospital and asked their permition to share their phone numbers.

- The discussion must include a comparison of this study and reference 41 (authored by Lataifeh and colleagues). They look very similar. Additional context is needed.

Thank you. The reference already included In paragraph 2 in the discussion (page 9). We added this: “Meanwhile, a study conducted among Jordanian HCWs showed 83.3% and 42.6% willingness towards COVID-19 vaccination in general among physicians and nurses respectively (41).”

- The first two paragraphs in the discussion have many in-text citations which see incorrect. For example, lines 24 and 25 mention a study on Arab HCWs but cites a study done in Germany. This article makes no mention of Arab or Jordanian workers specifically.

Thank you for this comment. You are correct the reference (33) is not reflecting the sentence. This is modified to the right reference which is (56). We amended it in the text (see page 9, paragraph 2, line 25). The other citations gives references to clarify discrepancy in the figures only.

Sincerely yours

Mohammad

Reviewer 3 Report (New Reviewer)

This article is exceptionally written well. It does claim that it identified barriers to take third dose of COVID 19 vaccination that could be addressed by the government to increase the COVID 19 vaccination uptake. This article would be very  interesting  to readers if percentage of physician  like internal medicine/ pulmonologist/ infectious disease involved were mentioned. I think there would be educational difference between patients of private and public sector rather than healthcare workers. 

Author Response

Reply to the Reviewers

 

 

Dear Doctor

Kindly see the followings response to your important notes regarding our manuscript.

Regards

Mohammad

 

 

Reviewer 3:

This article is exceptionally written well. It does claim that it identified barriers to take third dose of COVID 19 vaccination that could be addressed by the government to increase the COVID 19 vaccination uptake. This article would be very  interesting  to readers if percentage of physician  like internal medicine/ pulmonologist/ infectious disease involved were mentioned. I think there would be educational difference between patients of private and public sector rather than healthcare workers.

Thank you for your exceptional comments. We agree with you, it’s very interesting to mention the subspecialties. Hopefully what you point out can be done for future study. However, this study sample divisions according to what you described would not be significant , therefore we recommend to increase the sample size to go further in this type of analysis.

 

Sincerely yours

Mohammad

Reviewer 4 Report (New Reviewer)

In this cross-sectional study in Jordan, the study authors reported on the willingness of healthcare workers (HCWs) to recommend the third dose of the COVID-19 vaccine to their patients. Through online questionnaires of 300 HCWs, they noted that physicians and male HCWs were more likely to receive the 3^rd dose.

The study adds much needed information about the ongoing policy-implementation gaps that have been seen with the COVID-19 pandemic. There are certain points in the manuscript that will need further clarification.

 

Major Comments

1. The study authors note that a large number of vaccines from different manufacturers are currently offered in Jordan. As is well known, there is conflicting data regarding the reported efficacy of some of the COVID-19 vaccines versus others. Considering these factors, could the type of vaccine previously received (or planned to be available) have impacted the willingness of providers? Is the sub-group data related to type of previous vaccine administered available? This information may cause a subconscious bias in the minds of the respondents. In case this data is not available or cannot be objectively quantified, the study authors should consider adding that as a limitation in the study.  

2. Additionally, the respondents of the study were in four different centers in Jordan – it is unclear whether these hospitals were all larger tertiary care centers or some were smaller hospitals. In sub-group analysis, was there a difference between responses between HCWs at different centers? The differences could be because of the size and location of hospital, the availability of specialists for creating awareness about the vaccines or even the type of vaccines HCWs had received in that particular area. It would be important to highlight that information in a short line if there was no significant difference in responses (or if needed, in a table in the supplementary data).

3. In the Questionnaire in the Supplementary material, the study authors asked the question “In your opinion, for the population as a whole, how serious is COVID-19 on a scale of 0 to 10?” and sought responses on a scale of 1-10. I did not see the findings of that being reported in the study – was there a particular reason for it being excluded? It is understandable if the responses to that question were deemed too broad for interpretation. However, one can argue that the attitude of HCWs towards the severity of COVID-19 may also impact the willingness to receive and administer the 3rd dose.

 

Minor Comments

1. The study authors have described the place of work of the HCWs as public, private or teaching hospitals. However, they should also mention whether the HCWs were primarily working in inpatient or outpatient settings (it appears they were all in the inpatient setting).

2. Page 5 of 14, line 158 – the study authors mention in Table 2 that 148 respondents (49.4%) responded “Yes, certainly” to the question whether they would vaccinate themselves. However, in line 158, it has been noted as “49.3% certainly”. Please clarify the exact number in the text and/or in the table.

3. If feasible, the study authors should also note what types of vaccine information resources are currently available in Jordan (or were available in Jordan) at the time of the study – such as pamphlets, regular seminars or online webinars etc.

Author Response

Reply to the Reviewers

 

Dear Doctor

Kindly see the followings response to your important notes regarding our manuscript.

Regards

Mohammad

 

Reviewer 4:

In this cross-sectional study in Jordan, the study authors reported on the willingness of healthcare workers (HCWs) to recommend the third dose of the COVID-19 vaccine to their patients. Through online questionnaires of 300 HCWs, they noted that physicians and male HCWs were more likely to receive the 3rd dose.

 

The study adds much needed information about the ongoing policy-implementation gaps that have been seen with the COVID-19 pandemic. There are certain points in the manuscript that will need further clarification.

Thank you for your constructive comments, extensive review and efforts you exercised in this manuscript. You raised an important points and we are responding to them according to the points below:

 

 

Major Comments

 

1. The study authors note that a large number of vaccines from different manufacturers are currently offered in Jordan. As is well known, there is conflicting data regarding the reported efficacy of some of the COVID-19 vaccines versus others. Considering these factors, could the type of vaccine previously received (or planned to be available) have impacted the willingness of providers? Is the sub-group data related to type of previous vaccine administered available? This information may cause a subconscious bias in the minds of the respondents. In case this data is not available or cannot be objectively quantified, the study authors should consider adding that as a limitation in the study.

Good point described here. We did not go to this part because the vaccine’s type received by the participant was not identified in our survey. We added the following in the limitation section (see page 10 last paragraph):

Another point we discovered it during the analysis, that we cannot link the vaccine type received by the participant to his/her willingness to recommend any vaccine. The same applied when we consider HCWs knowledge about the reported efficacy of some of the COVID-19 vaccines versus others. Therefore, these points recommended in future studies.

2. Additionally, the respondents of the study were in four different centers in Jordan – it is unclear whether these hospitals were all larger tertiary care centers or some were smaller hospitals. In sub-group analysis, was there a difference between responses between HCWs at different centers? The differences could be because of the size and location of hospital, the availability of specialists for creating awareness about the vaccines or even the type of vaccines HCWs had received in that particular area. It would be important to highlight that information in a short line if there was no significant difference in responses (or if needed, in a table in the supplementary data).

We amended the sampling section to indicate that we selected large central hospitals in the three regions of Jordan. Therefore the hospitals are comparable in terms of size and employees size of HCWs (see page 3, last two paragraphs).

 

3. In the Questionnaire in the Supplementary material, the study authors asked the question “In your opinion, for the population as a whole, how serious is COVID-19 on a scale of 0 to 10?” and sought responses on a scale of 1-10. I did not see the findings of that being reported in the study – was there a particular reason for it being excluded? It is understandable if the responses to that question were deemed too broad for interpretation. However, one can argue that the attitude of HCWs towards the severity of COVID-19 may also impact the willingness to receive and administer the 3rd dose.

Thank you for this deep understanding of the topic. The research team discussed between them during the reporting of the results this item and agreed to exclude it. The question could be directed to the general public rather than the HCWs. Furthermore, the HCWs responses require broad interpretation which does not go with the focus of the topic.

 

 

Minor Comments

 

1. The study authors have described the place of work of the HCWs as public, private or teaching hospitals. However, they should also mention whether the HCWs were primarily working in inpatient or outpatient settings (it appears they were all in the inpatient setting).

Thank you for this point. All the participants are working in the inpatient departments. However, some of them are working as part timers in the out patient departments such as the specialists who have clinics. This was not included in the survey too. Primary care departments not included here, therefore we assume that all respondents have direct contact with in patients even partially.

 

2. Page 5 of 14, line 158 – the study authors mention in Table 2 that 148 respondents (49.4%) responded “Yes, certainly” to the question whether they would vaccinate themselves. However, in line 158, it has been noted as “49.3% certainly”. Please clarify the exact number in the text and/or in the table.

Thank you. Amended to 49.4% (this is the correct percentage)

3. If feasible, the study authors should also note what types of vaccine information resources are currently available in Jordan (or were available in Jordan) at the time of the study – such as pamphlets, regular seminars or online webinars etc.

We believe as a research team, This may affect the knowledge and attitudes of the general public rather than the HCWs. Most of the HCWs who are working in the vaccines campaigns to our knowledge attended seminars and workshops. We understand your recommendation becomes feasible to ask it for this subgroup of participants rather than all HCWs who work in the hospitals.

 

Sincerely yours

Mohammed

Round 2

Reviewer 2 Report (New Reviewer)

I thank the lead author for their repl. I am content with the majority of their edits. 

However, the most significant issue I previously identified was the use of the Chi-squared test. As I consider the study again, I realize that the authors probably did not use the Chi-squared goodness of fit test (which I am more familiar with), but probably used the Chi-squared test of independence. A more detailed explanation of the statistical analysis is needed. Another sentence or two in the statistical analysis section of the methods would help.

Author Response

 

Dear Doctor

Kindly see the followings response to your important note regarding our manuscript.

Regards

Mohammad

 

Reply to the Reviewer

However, the most significant issue I previously identified was the use of the Chi-squared test. As I consider the study again, I realize that the authors probably did not use the Chi-squared goodness of fit test (which I am more familiar with), but probably used the Chi-squared test of independence. A more detailed explanation of the statistical analysis is needed. Another sentence or two in the statistical analysis section of the methods would help.

Thank you for your clarification. We added the following two sentences in page 4 line 150-153:

The Chi-squared test of independence is a statistical test used to determine whether there is a significant association between two categorical variables. It is often used to analyze the relationship between variables in a contingency table.

 

Sincerely yours

Mohammad

Reviewer 4 Report (New Reviewer)

The study authors have incorporated the suggestions that were previously raised and have addressed the points that could not be added. I have no major comments to add, just some minor comments as below.

 

Minor Comments:

1. Pages 3 and 4 of 15, lines 123-137 – The study authors have described in elaborate detail the collection of phone numbers of the healthcare workers through the Human Resources department. This information does not appear to add additional useful information to the study. I would suggest shortening it to something along the lines of – “Four hospitals participated in our study – the King Abdullah University Hospital in the north, the Arab Private Medical Center and the Jordan University Hospital in the middle, and Al-Karak Governmental Hospital in the south. The four hospitals selected had responded to our invitation sent to all central hospitals with large number of HCWs and they were representative of the three regions of Jordan. With the permission of the human resource department in each hospital, HCWs were randomly selected and sent a WhatsApp message containing a link to the questionnaire.”

2. Adding to the above comment, the second half of that paragraph (as below) would be better in the Results section: “Among the total number of 450 WhatsApp messages, 300 physicians, nurses and pharmacists confirmed their participation, with a response rate of 66.7%. This provided a sufficient sample size for a power of 90% 136 with a margin of 5%.”

3. Page 10/15, lines 87-91 – the authors should consider a modification of this sentence for ease of reading. Here is an example of that “Another point we discovered during the analysis was that the vaccine type received by the HCW could not be linked to his/her willingness to recommend any vaccine. This point was also applicable when we considered HCWs knowledge about the reported efficacy of some of the COVID-19 vaccines versus others. These points should be studied in detail in future studies.”

Author Response

 

Dear Doctor

Kindly see the followings response to your important note regarding our manuscript.

Regards

Mohammad

 

Minor Comments:

1. Pages 3 and 4 of 15, lines 123-137 – The study authors have described in elaborate detail the collection of phone numbers of the healthcare workers through the Human Resources department. This information does not appear to add additional useful information to the study. I would suggest shortening it to something along the lines of – “Four hospitals participated in our study – the King Abdullah University Hospital in the north, the Arab Private Medical Center and the Jordan University Hospital in the middle, and Al-Karak Governmental Hospital in the south. The four hospitals selected had responded to our invitation sent to all central hospitals with large number of HCWs and they were representative of the three regions of Jordan. With the permission of the human resource department in each hospital, HCWs were randomly selected and sent a WhatsApp message containing a link to the questionnaire.”

Thank you. Amended in page 3 line 132-139. Second part of the paragraph deleted as directed in next comment.

2. Adding to the above comment, the second half of that paragraph (as below) would be better in the Results section: “Among the total number of 450 WhatsApp messages, 300 physicians, nurses and pharmacists confirmed their participation, with a response rate of 66.7%. This provided a sufficient sample size for a power of 90% 136 with a margin of 5%.”

Good point. This transferred to results section with minor modifications to remove the repetition.  (see page 4 line 158-162)

3. Page 10/15, lines 87-91 – the authors should consider a modification of this sentence for ease of reading. Here is an example of that “Another point we discovered during the analysis was that the vaccine type received by the HCW could not be linked to his/her willingness to recommend any vaccine. This point was also applicable when we considered HCWs knowledge about the reported efficacy of some of the COVID-19 vaccines versus others. These points should be studied in detail in future studies.”

Thank you for this suggestion. We modified it in the text as described. (see page 10 line 93-97).

 

Sincerely yours

Mohammad

 

 

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Title: Willingness of Healthcare Workers towards the third, Booster, COVID-19 Vaccine Dose: A Cross-Sectional Study from Jordan Authors: Mohammad Abu Lubad *, Munir A Abu-Helalah, Israa F Alahmad, Malak M Al-Tamimi, Mohammad S QawaQzeh, Ahlam M Al-kharabsheh, Hamed Alzoubi, Khalid A Kheirallah Submitted to section: Immunology and Vaccines  

The manuscript is very interesting but few improvements are required before its publication  

Abstract. ok

Introduction. ok

Methods.

- Hows sample size is calculated?

- Inclusion and Exclusion criteria?

Results

- Hows the questionaire is validated?

- Explain the other parameters in results if you have more data

Discussion - Add some latest citations  

 

Author Response

Dear Doctor

Kindly see the following responses to your important notes regarding our manuscript.

Kind regards

 

The manuscript is very interesting but few improvements are required before its publication  

Abstract. ok

Introduction. Ok

 

Methods.

1. Hows sample size is calculated?

Thank you for this valuable note. The estimated number of physicians in Jordan is 30,000. A sample size of 270 participants is required for confidence interval of 90% and margin of error of 5%.

2. Inclusion and Exclusion criteria?

• The inclusion criteria are already included in text lines 89-91.
• We added one exclusion criterion including the participants who were not Jordanian were excluded from the study in lines 91-92.

 

Results

3. Hows the questionnaire is validated?

• Our reply on this appreciated note is that this questionnaire was prepared through literature review and experts opinion. This was piloted on 30 physicians and edited accordingly. No validation study was required because a total score was not calculated. It is a general survey on attitudes and uptake rate.

4. Explain the other parameters in results if you have more data

• All parameters were included in the analysis.

Discussion

5. Add some latest citations  

     5 references were added with numbers 36, 43, 46, and 45

 

 

Reviewer 2 Report

Dear authors,

I have received an article which attempts to look at the willingness of healthcare workers (HCWs) in Jordan to be vaccinated with COVID-19 booster. Only 49% of the HCW are willing to be vaccinated. While I commend the efforts, some issues need to be fixed:

Major Issues

Title

Please decide whether to use "third" or "booster" in the title. Either one is fine, but not both.

Introduction

- The introduction (lines 45-63) explains hesitancy, while the title is about willingness. The authors should revise this introduction and explain more about vaccine acceptance. 

- Lines 68-73 --> This part explains in great detail another study which is not needed in remarkable fact. Please summarize them and cite the study.

- The authors need to acknowledge other studies conducted in Jordan and redirect the novelty to saying, "despite studies have been done in Jordan about willingness to receive the third dose, the willingness in HCWs is unknown. This is important because...." and please cite these three studies done in Jordan previously about booster doses:

1) https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0271625
2) https://www.europeanreview.org/wp/wp-content/uploads/7516-7525.pdf
3) https://www.mdpi.com/2076-393X/10/3/410/htm

Methods

- The authors should define vaccine willingness or acceptance in this study.  In lines 137-8, the authors mention that vaccine acceptance is 68.3% (+ probably), but the abstract only says 49% (- probably). The authors should be consistent with the definition and explicitly mention the illustrations. 

- Please include the list of questions in a supplementary material

- Please include the sample size calculation so that the authors can back up the sentence, "This provides a sufficient sample size..."

- Lines 101-102 -- Please provide a CONSORT diagram, as this sentence is confusing. Only 300 respondents are obtained, but there are also exclusions, and the total number is still 300.

- The authors need to specify further what statistical analysis is done because mentioning "using SPSS" is not enough.

Results

- The authors sent 570 messages in the methods section, while the authors only mention 450 messages in the results section. Which one is the correct one?

- Please merge the number and % for an easier read. Also, please include a median or mean age. Some spelling and margin errors also occur here (e.g. single while it should be Single).

- The authors include the intention to recommend the COVID-19 booster dose in table 2. Why is this being studied when the aim of the study is not this topic? The authors should explain this somewhere.

- Line 155-167 --> This statistical analysis is not correct as there is no baseline for reference. The correct interpretation should be "There is a statistically significant difference between the three groups with an OR of .. and p-value of ..", but there is no way to know which group is which with this statistical analysis.

- I do not get table 4. The authors look at willingness for COVID-19 booster (Yes vs No) and some questions such as "The safety of a vaccine developed in an emergency cannot be considered guaranteed", and it is categorized as Agree, Disagree, and Do Not Know. This is very confusing as I do not understand what the authors are trying to achieve here or what this even means. Either remove them from the analysis or present these parts as a separate table.

Discussion

- Lines 171-172 --> The authors specifically mention the intention to recommend, which is not said in the aim of the study.

- Lines 177-187 --> Are we comparing studies that look at HCW too?

- Lines 213-216 --> These lines do not explain why physicians are more willing to receive the third booster dose. Instead, it explains about nurses, which are entirely unrelated.

- Lines 217-218 --> This statement is not brought up in the results section

- Lines 222-228 --> no results back this statement. While the aim of the study looks at barriers to uptake, there is nowhere in the results that look at these, and instead, the authors look at the intention to recommend.

- Lines 236-241 --> When is this brought up in the results?

- The authors should include limitations (surveys via WhatsApp, low response rate, etc.) and strengths.

- This article could benefit from these studies:
1) https://www.sciencedirect.com/science/article/pii/S1576988722000656
2) https://www.mdpi.com/2414-6366/7/11/361
3) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8685827/

Minor Issues

- MDPI's abstract is unstructured. Please fix that.

- The authors need to improve their spelling, capitalization, and punctuation, such as HCW and Pharmacist (P is always in capital letters regardless of their position in a sentence). Also, booster, not "boaster".

- Lines 81-82 --> redundant, as it is already mentioned in the introduction section

Author Response

Dear Doctor

Kindly see the followings response to your important notes regarding our manuscript.

Kind regards

Mohammad

 

Major Issues

Title

1. Please decide whether to use "third" or "booster" in the title. Either one is fine, but not both.

• Thank you and we decided to use "third” only in the title.

Introduction

2. The introduction (lines 45-63) explains hesitancy, while the title is about willingness. The authors should revise this introduction and explain more about vaccine acceptance. 

Very helpful comment. We have edited the introduction and showed the difference between unwillingness and hesitancy in lines 47-51. This report focuses only on unwillingness.

The World Health Organization defines vaccine hesitancy as a “delay in acceptance or refusal of vaccines despite availability of vaccination services,” while vaccination unwillingness refers to “the refusal to be vaccinated.” COVID-19 vaccine unwillingness can be major barrier in achieving adequate vaccine coverage to contain the pandemic (5-7)

 

3. Lines 68-73 --> This part explains in great detail another study which is not needed in remarkable fact. Please summarize them and cite the study.

Very helpful note. We deleted the unimportant part of the paragraph with the addition of its corresponding reference. 

 

Another cross-sectional study from Jordan included 915 adults evaluated hesitancy toward COVID-19 third dose among general population with almost half of the participants (56.4%) intended to decline the booster dose of the COVID-19 vaccine (14). Key reported barriers for the uptake were: “The benefits of booster dose have not been scientifically proven” (39.8%), followed by “I took the last dose a short time ago, and there will be no need to take the booster dose for at least a year” (24.6%). In turn, “I was infected with COVID-19; thus, I do not require the booster dose” was the least reported reason (13.1%).

4. The authors need to acknowledge other studies conducted in Jordan and redirect the novelty to saying, "despite studies have been done in Jordan about willingness to receive the third dose, the willingness in HCWs is unknown. This is important because...." and please cite these three studies done in Jordan previously about booster doses:

1)https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0271625
2)https://www.europeanreview.org/wp/wp-content/uploads/7516-7525.pdf
3) https://www.mdpi.com/2076-393X/10/3/410/htm

• Thank you for this missing information. We added the two lines (72-73) in the introduction as you recommended with the references numbers (14, 15, 16).

Methods

5. The authors should define vaccine willingness or acceptance in this study.  In lines 137-8, the authors mention that vaccine acceptance is 68.3% (+ probably), but the abstract only says 49% (- probably). The authors should be consistent with the definition and explicitly mention the illustrations. 

• We have edited the abstract and the results are currently consistent between the abstract and the results section.

 “HCW overall willingness towards the third dose vaccine was 68.3% (49.3% certainly, and 19.0% probably). While the overall willingness of the HCW to recommend the third dose to their patients was 73.3% (49.0% certainly, 24.3% probably)”.

6. Please include the list of questions in a supplementary material

• Yes, we will write a note in the methodology that the list of questions will be included in a supplementary material (lines 118-119).
• The link to the list of questions:

https://docs.google.com/forms/d/1Korbotbt-uf8cCu3-yRFvsxml4601nrzgE_mtH0F2tw/viewform?ts=61bdedca&edit_requested=true

7. Please include the sample size calculation so that the authors can back up the sentence, "This provides a sufficient sample size..."

Thank you for this appreciated request. We have edited the statistical analysis section and added the followings:

• In lines 121-122, we added that the estimated number of physicians in Jordan is 30,000. A sample size of 270 participants is required for confidence interval of 90% and margin of error of 5%.

8. Lines 101-102 -- Please provide a CONSORT diagram, as this sentence is confusing. Only 300 respondents are obtained, but there are also exclusions, and the total number is still 300.

• We have edited this paragraph.

9. The authors need to specify further what statistical analysis is done because mentioning "using SPSS" is not enough.

• Thank you for this helpful feedback. We have edited the statistical analysis section and provided more details.

 

Results

10. The authors sent 570 messages in the methods section, while the authors only mention 450 messages in the results section. Which one is the correct one?

• Thank you for this note. 450 messages not 570 were sent for all HCWs and this was fixed in the text.

11. Please merge the number and % for an easier read. Also, please include a median or mean age. Some spelling and margin errors also occur here (e.g. single while it should be Single).

• Thank you very much. We merged the number and % and we fix some margin errors.

12. The authors include the intention to recommend the COVID-19 booster dose in table 2. Why is this being studied when the aim of the study is not this topic? The authors should explain this somewhere.

• Vaccines unwillingness among healthcare professionals could affect their advice or decision of vaccination for their patients. Therefore, it was essential to study the practice of recommending the vaccine amongst study participants.

13. Line 155-167 --> This statistical analysis is not correct as there is no baseline for reference. The correct interpretation should be "There is a statistically significant difference between the three groups with an OR of .. and p-value of ..", but there is no way to know which group is which with this statistical analysis.

• Table 4 shows the rates and P-value per profession.

14. I do not get table 4. The authors look at willingness for COVID-19 booster (Yes vs No) and some questions such as "The safety of a vaccine developed in an emergency cannot be considered guaranteed", and it is categorized as Agree, Disagree, and Do Not Know. This is very confusing as I do not understand what the authors are trying to achieve here or what this even means. Either remove them from the analysis or present these parts as a separate table.

• The idea of this table is show results of chi-square analysis for different important variables and the unwillingness to take the third dose of the vaccine.

The safety of a vaccine developed in an emergency, cannot be considered guaranteed” helped to assess the belief that “vaccine safety could not be guaranteed” whether or not will affect the willingness to take the booster dose.

Discussion

15. Lines 171-172 --> The authors specifically mention the intention to recommend, which is not said in the aim of the study.

• As stated above, Vaccines unwillingness among healthcare professionals could affect their advice or decision of vaccination for their patients. Therefore, it was essential to study the practice of recommending the vaccine amongst study participants.

 

16. Lines 177-187 --> Are we comparing studies that look at HCW too?

• Yes, all studies compare the attitude among HCWs in different countries

17. Lines 213-216 --> These lines do not explain why physicians are more willing to receive the third booster dose. Instead, it explains about nurses, which are entirely unrelated.

We would to thank you for this correction.

The paragraph “The positive attitude of the nurses towards the COVID-19 vaccines is highly significant because of their direct and long duration contact with their patients. Therefore, they might alter their patients’ attitudes towards the vaccine”.

Will be replaced by this paragraph in lines 216-220:

The positive attitude of the physicians towards the COVID-19 vaccines is highly significant because of their anticipated risk of getting infected with COVID-19 and direct care for patients were also found to increase COVID-19 vaccination uptake probability.

 

18. Lines 217-218 --> This statement is not brought up in the results section.

• This was shown in table 4.

19. Lines 222-228 --> no results back this statement. While the aim of the study looks at barriers to uptake, there is nowhere in the results that look at these, and instead, the authors look at the intention to recommend.

• Barriers were shown in table 4. Significant barriers were working at public sector, being a pharmacist or nurse compared with physicians, belief in mistrust in the MoH.. etc.

20. Lines 236-241 --> When is this brought up in the results?

• This was brought up in table 4.

21. The authors should include limitations (surveys via WhatsApp, low response rate, etc.) and strengths.

• Thank you very much. Very helpful and important point. We have added a paragraph on study limitations (lines 246-248 in the new version).

- Minor Issues

22. MDPI's abstract is unstructured. Please fix that.

Yes, and thank you. We restructured the abstract based on MDPI instructions:

Abstract: Background The availability of COVID-19 vaccines worldwide necessitates measuring the healthcare workers (HCW) willingness towards these vaccines. Therefore, we proposed to conduct a local study in Jordan to assess HCW’ willingness towards the third dose of COVID-19 vaccine and predictors of such decision. A cross-sectional study investigated the Jordanians' HCW’ willingness towards the third dose of COVID-19 vaccine using a self-administered online questionnaire through mobile phone WhatsApp application.  A total of 300 HCW participated in the current study. Of which, 65.3% were physicians, 25.3% were nurses, and 9.3% were Pharmacists. HCW overall willingness towards the third dose vaccine was 68.3% (49.3% certainly, and 19.0% probably). While the overall willingness of the HCW to recommend the third dose to their patients was 73.3% (49.0% certainly, 24.3% probably). Males had significantly higher willingness than females (82.1% vs. 60.1%, P<0.05). Physicians reported more willingness than nurses and Pharmacists. HCW willingness level was not significantly different by direct contact of COVID-19 patients, or by history of COVID-19 infection. Only 31% of HCW were certain to recommend the vaccine to their patients with chronic diseases and only 28% of the participants were certain to recommend it for people aged 65 or older. HCW's willingness to receive the third dose of COVID-19 vaccine is limited in Jordan. This has affected their certainty in recommended this vaccine for their patients or people older than age 60. Decision makers and health promotions programs in Jordan should focus on sorting this public health problem.

 

23. The authors need to improve their spelling, capitalization, and punctuation, such as HCW and Pharmacist (P is always in capital letters regardless of their position in a sentence). Also, booster, not "boaster".

• This has been done.

24. Lines 81-82 --> redundant, as it is already mentioned in the introduction section

• This has been edited.

 

 

Reviewer 3 Report

The introduction and discussion needs to be precise and to the point

 

Introduction

(line 52) the authors state :"COVID-19 and its variants..". The acronym COVID-19 (Coronavirus 2019) indicates the disease and not the virus (SARS-CoV-2). Therefore, it is not correct to define "its variants".

(line 51-52) the authors write : "the three-dose vaccine program could be helpful in reducing the risk of...variants infection). They should make this statement clearer. The vaccine and booster dose can induce a lower viral load and milder clinical symptoms (Nat Med. 2021;27(12):2108-10; Lancet 2022;399(10325):625-6) rather than reducing the risk of infection.

(line 62) the author define in full the acronym GED  (general Educational Development).

Discussion

the authors indicate some characteristics (male sex, medical profession, workplace...) as predictive factors related to the willingness to receive a complete vaccination protocol. However, we believe it is appropriate to set up a more complex statistical analysis in order to obtain statistically reliable results.

References

The authors check the spelling of the references and make the appropriate corrections.

 

Author Response

Dear Doctor

Kindly see the followings response to your important notes regarding our manuscript.

Kind regards

Mohammad

 

Comments and Suggestions for Authors

1. The introduction and discussion needs to be precise and to the point

• Thank you very much. The introduction and discussion were r

 

Introduction

2. (line 52) the authors state :"COVID-19 and its variants..". The acronym COVID-19 (Coronavirus 2019) indicates the disease and not the virus (SARS-CoV-2). Therefore, it is not correct to define "its variants".

• We have edited this accordingly. We replaced COVID-19 with SARS-Cov-2.

3. (line 51-52) the authors write : "the three-dose vaccine program could be helpful in reducing the risk of...variants infection). They should make this statement clearer. The vaccine and booster dose can induce a lower viral load and milder clinical symptoms (Nat Med. 2021;27(12):2108-10; Lancet 2022;399(10325):625-6) rather than reducing the risk of infection.

• This was explained in lines 54-62

4. (line 62) the author define in full the acronym GED  (general Educational Development).

• We have edited it and make it as a general lower education scores at high schools.

Discussion

5. the authors indicate some characteristics (male sex, medical profession, workplace...) as predictive factors related to the willingness to receive a complete vaccination protocol. However, we believe it is appropriate to set up a more complex statistical analysis in order to obtain statistically reliable results.

• Yes, we included a chi-square analysis in

References

6. The authors check the spelling of the references and make the appropriate corrections.

 

 

 

Reviewer 4 Report

thanks for that work addressing jordanian HCWs attitude toward third booster dose of COVID-19 vaccine.

 

I have couple of comments that needs your reply kindly:

 

Needs English language editing

Why did you exclude non Jordanian HCWs even  though they  practice in Jordan

Please submit the survey in PDF rather than fillable google forms

Any explanation for the very high percentage of participants that didn’t have contact with COVID-19 patients?  And do you think this has affected the results?

Why did you ask the willingness question in negative way in Table 3? And do you think this led to misunderstanding to the participants?

Tables especially table 4 needs better organization as number are confusing

Your discussion mainly concentrated on general hesitancy/willingness for vaccination while the paper is targeting booster third dose which was administered in many countries whether to HCWs or public, you can review literature in that regard and critically appraise it and compare it to your results.

You need to consider that the most recent variants of SARS CoV 2 cause benign disease in the majority of patients which presented with Flu like illness , do you think  this contributed to the hesitancy for third dose?

Your country administered live attenuated virus vaccine which might increase hesitancy , how do you think this affected the rate of hesitancy compared to other countries that mainly administered mRNA vaccine like Pfizer-Biontech which also has very benign profile of side effects.

Please discuss the effect of collective responsibility to the community and its contribution to the rate of hesitancy for third booster dose

Author Response

Dear Doctor

Kindly see the followings response to your important notes regarding our manuscript.

Regards

Mohammad

 

• Needs English language editing

Thank you. The manuscript has undergone English language editing by MDPI. The text has been checked for correct use of grammar and common technical terms, and edited to a level suitable for reporting research in a scholarly journal.

 

 

• Why did you exclude non Jordanian HCWs even though they practice in Jordan?

Thanks loads. We added this point to the limitations and provided above justification “Many non-Jordanian healthcare workers are working on temporary basis, therefore, the decision was to exclude this important group (lines 278-280).

 

• Please submit the survey in PDF rather than fillable google forms?

Thank you very much. The survey in PDF will sent with the revised manuscript.

 

• Any explanation for the very high percentage of participants that didn’t have contact with COVID-19 patients?  And do you think this has affected the results?

Very important question. Thank you!

During the pandemic, special hospitals were allocated for management of COVID-19.

Subgroup analysis showed no difference between those with direct contact and those without direct contact (lines 240-243).

 

• Why did you ask the willingness question in negative way in Table 3? And do you think this led to misunderstanding to the participants?

This can be asked in both ways. We wanted to highlight on the unwillingness of the HCW to recommend the third dose to his/her patients. This will more clearly reveal the impact of unwillingness to receive the third dose, on the HCW recommendation of the third dose to his/her patients.

• Tables especially table 4 needs better organization as number are confusing?

Thank loads. Table 4 was reformatted to be more clear.

 

• Your discussion mainly concentrated on general hesitancy/willingness for vaccination while the paper is targeting booster third dose which was administered in many countries whether to HCWs or public, you can review literature in that regard and critically appraise it and compare it to your results.

 

Thanks a lot. We covered both the general hesitancy and hesitancy towards the third dose. There are limited published literature on the third dose and we covered most of them in addition to the following paragraph that shows the published data on the willingness of HCW towards the third dose of COVID-19 (Lines 215-222)  

 

• You need to consider that the most recent variants of SARS CoV 2 cause benign disease in the majority of patients which presented with Flu like illness, do you think this contributed to the hesitancy for third dose?

Excellent feedback that we highly appreciate. We have added a new paragraph near the end of the discussion to show this potential impact as a limitation for the study (lines 275-278).

 

• Your country administered live attenuated virus vaccine, which might increase hesitancy, how do you think this affected the rate of hesitancy compared to other countries that mainly administered mRNA vaccine like Pfizer-Biontech, which also has very benign profile of side effects.

 

The policy of ministry of health in Jordan during the COVID-19 pandemic was to administer all the available types of vaccine and therefore, Jordanian people in general are free to choose among them.  Therefore, we believe that this point is not applicable locally due to the free selection between several vaccines.

 

• Please discuss the effect of collective responsibility to the community and its contribution to the rate of hesitancy for third booster dose

Thanks loads, we covered the impact for the community in the conclusion

 

Sincerely yours

Mohammad

 

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

Dear Editor,

I have received the revision, and while some modifications are adequate, there are still some necessary changes:

1. In the introduction section, the author focuses on unwillingness, while the title is willingness. This is an entirely different spectrum. Discussing reluctance does not correlate to solving the desire to be vaccinated. Hence, the introduction needs to be centered around the theory of readiness for vaccination. The authors can refer to the opening and theories of the willingness to vaccination in this article (https://www.mdpi.com/2414-6366/7/11/361)

2. In the methods section, the authors still do not define "vaccine willingness," which will affect the results. It should be stated clearly prior in the methods section and not be inferred in the results section.

3. Please list all the questions in the supplementary material and do not copy and paste the link, as the link may disappear one day.

4. The estimated number of physicians in Jordan is 30,000 --> Is there any citations to back this fact up? Also, what formula is used to calculate this sample size?

5. Statistical analysis is still not described here. The authors merely state what is descriptive and continuous variables without any explanations on what statistical analysis (e.g., chi-squared, t-test on what variables, etc.) was done

6. "Vaccines unwillingness among healthcare professionals could affect their advice or decision of vaccination for their patients. Therefore, it was essential to study the practice of recommending the vaccine among study participants" --> While I understand this reasoning, the authors still need to mention it in the aim of the study as a secondary methodology. If this is important, the authors also need to include some background in terms of intention to recommend in the introduction section and potentially to change the title.

7. Presentation of table 4 is poor, with the text not aligning with each other. Also, the fact that the authors mention the category of jobs as their defense of the baseline category means that they do not understand fundamental statistical analysis. I suggest all the authors consult a biostatistician for this article.

8. "The idea of this table is to show the results of chi-square analysis for different important variables and the unwillingness to take the third dose of the vaccine. The safety of a vaccine developed in an emergency cannot be considered guaranteed" helped to assess the belief that "vaccine safety could not be guaranteed" whether or not will affect the willingness to take the booster dose." --> The authors miss a critical point here. This is not about that particular statement but how the question and answer are designed. If one chooses to answer agree, there is a yes and no question. If one chooses yes to settle, why is there an option to disagree with a yes or no question? This potentially points out a lousy question structuring.

9. "Yes, all studies compare the attitude among HCWs in different countries" --> Please clarify in the text that these studies are looking at HCWs.

10. Lines 217-221 are not cited

11. I still can find the word "boaster" everywhere. Please use control search and type "boaster"; it is still prevalent in the text. Please consult a native proofreader, and please do not just fixate on "boaster" but the whole spelling and grammar issues.

Author Response

Dear Doctor

Kindly see the followings response to your important notes regarding our manuscript.

Regards

Mohammad

I have received the revision, and while some modifications are adequate, there are still some necessary changes:

1. In the introduction section, the author focuses on unwillingness, while the title is willingness. This is an entirely different spectrum. Discussing reluctance does not correlate to solving the desire to be vaccinated. Hence, the introduction needs to be centered around the theory of readiness for vaccination. The authors can refer to the opening and theories of the willingness to vaccination in this article (https://www.mdpi.com/2414-6366/7/11/361)

 Important feedback. However, as stated in the previous feedback, we followed the WHO definition for unwillingness.

We have edited the introduction and showed the difference between unwillingness and hesitancy in lines (Lines 49-52). This report focuses only on unwillingness.

2. In the methods section, the authors still do not define "vaccine willingness," which will affect the results. It should be stated clearly prior in the methods section and not be inferred in the results section.

Thanks a lot. It has been added to the introduction (Lines 53-55).

3. Please list all the questions in the supplementary material and do not copy and paste the link, as the link may disappear one day.

Important feedback. The list of questions will be sent in a PDF format.

4. The estimated number of physicians in Jordan is 30,000 --> Is there any citations to back this fact up? Also, what formula is used to calculate this sample size?

This was not included by mistake.  The citation number is 22.

Kish formula was used to calculte the sample size.

5. Statistical analysis is still not described here. The authors merely state what is descriptive and continuous variables without any explanations on what statistical analysis (e.g., chi-squared, t-test on what variables, etc.) was done

Thanks a lot. We have explained this further in the statistical analysis plan.

6. "Vaccines unwillingness among healthcare professionals could affect their advice or decision of vaccination for their patients. Therefore, it was essential to study the practice of recommending the vaccine among study participants" --> While I understand this reasoning, the authors still need to mention it in the aim of the study as a secondary methodology. If this is important, the authors also need to include some background in terms of intention to recommend in the introduction section and potentially to change the title.

This was covered thoroughly in the introduction, results and discussion. Regarding the point ‘Therefore, it was essential to study the practice of recommending the vaccine among study participants’ this was covered in tables 3 and 4. 

The second point ‘While I understand this reasoning, the authors still need to mention it in the aim of the study as a secondary methodology’ this was included in the methodology lines 87-91.

Regarding ‘the authors also need to include some background in terms of intention to recommend in the introduction section and potentially to change the title’ some background was added (lines 66-71) and the title was changes accordingly.

7. Presentation of table 4 is poor, with the text not aligning with each other. Also, the fact that the authors mention the category of jobs as their defense of the baseline category means that they do not understand fundamental statistical analysis. I suggest all the authors consult a biostatistician for this article.

Thanks loads. We have edited it accordingly.

8. "The idea of this table is to show the results of chi-square analysis for different important variables and the unwillingness to take the third dose of the vaccine. The safety of a vaccine developed in an emergency cannot be considered guaranteed" helped to assess the belief that "vaccine safety could not be guaranteed" whether or not will affect the willingness to take the booster dose." --> The authors miss a critical point here. This is not about that particular statement but how the question and answer are designed. If one chooses to answer agree, there is a yes and no question. If one chooses yes to settle, why is there an option to disagree with a yes or no question? This potentially points out a lousy question structuring.

We agree that we have more categories such as "Strongly agree" , "agree"  it would be more helpful. However, where the sample size is smaller than 1000, we often combine these responses "Strongly agree/agree" to allow comparison based on good numbers.

9. 9. "Yes, all studies compare the attitude among HCWs in different countries" --> Please clarify in the text that these studies are looking at HCWs.

Done with many thanks.

10. Lines 217-221 are not cited

Thanks loads. We did some changes (lines 241-244) and we added three references 51-53

11. I still can find the word "boaster" everywhere. Please use control search and type "boaster"; it is still prevalent in the text. Please consult a native proofreader, and please do not just fixate on "boaster" but the whole spelling and grammar issues.

Corrected with many thanks.

Sincerely

Mohammad

Author Response File: Author Response.docx

Reviewer 3 Report

The authors responded exhaustively to the clarifications requested 

Author Response

Dear Doctor

Thank you for your respond that indicated our clarifications were done.

Regards

Mohammad

 

Sincerely yours

Mohammad

Author Response File: Author Response.docx