Vaccination is universally recognized as a significant and ef fective public health advancement in the prevention of infec tious diseases that can reduce morbidity, mortality, and health related costs [1,2].

Since their introduction in the 18th century, alongside the increase in the use and popularity of vaccines, the public has been concerned about their safety and effectiveness. This loss of confidence, known as “vaccine hesitancy,” involves both vac cinated and unvaccinated individuals. Observable among both healthcare workers and the general population, the Covid-19 pandemic has brought it into sharper focus [3].

WHO classifies vaccine hesitancy as one of the ten (10) most significant threats to global health. Indeed, low vaccination coverage, particularly among healthcare workers, can lead to epidemics, increase absenteeism, and reduce productivity [4].

Therefore, mandatory vaccination has been instituted for healthcare workers in some countries, such as France, for hepa titis B since 1991, leading to a considerable reduction in the in cidence of this work-related disease [5].

With the emergence of Covid-19, law no. 2021-1040 of Au gust 5, 2021, introduced mandatory vaccination for healthcare, social, and medico-social workers in France, and for access to specific places, leisure activities, and events. This measure was strongly contested by healthcare workers.

In Côte d’Ivoire, as in most African countries, there is no mandatory vaccination policy. Low vaccine coverage among healthcare workers is not only a public health issue but also an ethical one. It could reflect a lack of interest and/or a fail ure to recognize the importance of vaccination in protecting the health of medical staff and patients. The objective of this study was to examine the knowledge, attitudes, and practices of healthcare workers in two hospitals in Abidjan with regard to mandatory vaccination.

Study design and framework

We conducted a cross-sectional analytical study from Janu ary to March 2023, lasting three months. It took place in two healthcare facilities: the National Institute of Public Health in Treichville and the Port-Bouët General Hospital. The National Institute of Public Health (INHP) is a national public administra tive institution that focuses primarily on the prevention of in fectious diseases through vaccination, general hygiene, medical monitoring, and epidemiological surveillance. The Port-Bouët General Hospital primarily provides curative health care to the population.

Study population

Included in the study were all the healthcare workers in pre ventive and curative care services who were working in these facilities. These included medical staff, nurses, midwives, nurs ing assistants, senior healthcare technicians, laboratory techni cians, and students (medicine, INFAS).

Data collection

Data collection was carried out using an anonymous writ ten questionnaire, which was given to participants and then collected within an hour of completion. The recovery of questionnaires was associated with the verification of vaccination records for those who had them.

Definition of variables

The questionnaire covered socio-demographic and profes sional characteristics, their knowledge of vaccination and man datory vaccination, their perceptions and attitudes regarding mandatory vaccination, and their own vaccination status.

Analyses statistiques

Statistical analysis of the data was performed using SPSS 25 software. Descriptive statistics were presented as means with standard deviation and extremes for quantitative variables and as proportions for qualitative variables. Pearson’s chi-square test was used to test for correlation, with an expected signifi cance threshold set at p< .05 (α=5%).

Ethical considerations

To uphold ethical principles, we obtained authorisation from the Director General of Health of Côte d’Ivoire. Verbal consent to participate in the survey was requested from participants. The confidentiality of data was maintained and anonymous sta tus was respected.

Study population

Our study population consisted of 390 healthcare workers. Women accounted for 52.30% of respondents, with a sex ratio of 0.91. The average age was 38 (+/-3) years, with a minimum of 20 and a maximum of 56 years. Medical staff accounted for 26.15% of the study population and paramedical staff for 73.85%. This included nurses (40.77%), nursing assistants (17.43%), labora tory technicians (5.9%), midwives (4.62%), medical students (3.59%), and health technicians (1.54%). It should be noted that only 38 (9.74%) of them had previously received training in vac cinology prior to our study, and 381 (97.69%) had expressed a desire to receive such training.

Vaccination knowledge and mandatory vaccination

The vast majority of healthcare workers (90.25%) consid ered vaccines to be a way of preventing disease, while 2.56% considered it a way of curing disease. Seventy-two percent of the study population stated that vaccines were substances pre pared in laboratories from microorganisms (killed, inactive, or attenuated), and 41.02% considered vaccines to be medicines. Some stated that vaccines were serums (6.15%). According to 88.21% of respondents, mandatory vaccination exists in Côte d’Ivoire, and the vaccines concerned, mentioned by the re spondents, were BCG (76.45%), hepatitis B (58.13%), and MMR (54.36%). Among respondents, 64.61% said they were aware of vaccination for healthcare workers, and the reason given for this vaccination was prevention in 95.64% of cases.

Vaccination status

When asked about their compliance with the vaccination schedule for 14 vaccines recommended for healthcare workers, most respondents were up to date, according to their vaccination records, for yellow fever (82.54%) and COVID-19 (74.91%). Vac cination coverage was average for hepatitis B (70.54%) and men ingitis (68.36%). A small proportion of our study population was up to date with influenza (6.90%) and hepatitis A (1.09%) vaccina tions. Complete data on vaccination status are shown in Table 1.

Perceptions and attitudes of healthcare workers toward mandatory vaccination

Most healthcare workers believed that vaccines are impor tant for reducing and eliminating several diseases (87.69%) and useful for dealing with various epidemics, especially in develop ing countries (72.30%). Vaccination should therefore be a pre requisite for healthcare workers before practicing in the health care sector (74.36%), as it is a duty for healthcare professionals because they must be role models for patients (64.87%). The majority of respondents agreed with mandatory vaccination for healthcare workers (88.72%) Table 3.

Nevertheless, a few (11.28%) believed that vaccination should be a personal choice and not mandatory (10%), and also that it is patients who should be vaccinated to protect them selves against disease (1.28%).

When asked about their reasons for refusing mandatory vac cination, non-consenting healthcare workers most frequently cited fear of adverse effects (97.39%) and fear of becoming ill after being vaccinated (65.6%) Table 2.

Factors associated with mandatory vaccination

We investigated the factors associated with healthcare work ers’ acceptance of mandatory vaccination Table 3. Regarding socio-professional category, doctors (OR=1.26; P=0.001) were more likely to accept mandatory vaccination. No previous training in vaccinology (OR=1.73; P=0.02), having a vaccina tion record (OR=0.81; P˂0.001), and hearing about mandatory vaccination for healthcare workers (OR=1.87; P˂0.001) were sig nificantly associated with acceptance of mandatory vaccination.

Study population characteristics

Women’s predominance (52.30%) with a sex ratio of 0.91 confirms international trends toward feminization of the health workforce [6]. In addition, the predominance of paramedical staff in our study population (73.85%) is a characteristic found in several studies, notably that of Laraqui et al. in Morocco, with a proportion of 68.5%. This fact is frequently observed in urban health centers. [6,7]

The proportion of those who had received training in vaccin ology was low (9.74%). These findings are concerning because they involve the paramedical staff and almost all of the medical staff. Attoh et al. in Abidjan, in a study evaluating the training of Ivorian health professionals, highlighted the fact that trained health professionals had a better level of knowledge about vaccines and vaccine administration than those who were not trained [8].

Vaccination knowledge, mandatory vaccination, and vaccination status

Though most (90.25%) respondents mentioned vaccina tion as a preventitive measure, smaller proportions, 70.25% stated that vaccines were substances prepared in laboratories from microorganisms (killed, inactive or attenuated) and 6.25% stated that vaccines were serums. However, in the study by Nguefack et al. among the general population in Cameroon, the majority of mothers (99.2%) had very good knowledge of child hood vaccination and understood its definition [9]. The level of knowledge observed in our study is therefore low, given that the respondents were healthcare workers. In addition, 88.21% of respondents stated that mandatory vaccination existed in Côte d’Ivoire, which is not the case. This further illustrates their low level of knowledge on the subject of vaccination.

With regard to vaccination status, most respondents (70.51%) had a vaccination record. Yellow fever (82.54%) and COVID (74.91%) vaccines were administered to most respon dents based on their vaccination records, while viral hepatitis B coverage was lower (70.54%). However, hepatitis B transmis sion in hospitals is a significant risk. Vaccination against this disease is therefore mandatory for healthcare workers in some countries, including France [5] . Reducing transmission risk through vaccination may not be a concern for the 29.46% of our sample who are unimmunised. Nevertheless, frequent vaccine stockouts, observed in our context, could also be a factor in this situation.

For yellow fever, relatively high rates could be explained by the fact the antiamaril vaccine is mandatory for entering and leaving Côte d’Ivoire, regardless of the traveller’s destination. The COVID-19 vaccine was also required for entry into and exit from certain countries throughout the health emergency. It entitled the holder to a ‘health pass’ and was the subject of increased communication with healthcare workers, who were a target group.

Health workers’ perceptions and attitudes towards manda tory vaccination

For most respondents, vaccines are important for reducing and eliminating several diseases (87.6%). Thus, the majority (89%) agreed with compulsory vaccination for healthcare work ers, while 11% disagreed. Overall, the perception of the impor tance of vaccines in improving public health is positive, despite the infodemic and vaccine hesitancy among healthcare workers caused by COVID-19. A study by Navaré et al. in France, con ducted shortly before the advent of COVID-19 vaccines, found that only 35% of hospital workers were in favour of vaccination against COVID-19 [10].

Regarding the reason for refusing mandatory vaccination, fear of adverse effects was the main reason (97.39%). Most studies show this reason for vaccine refusal among healthcare workers and the general population. In Attoh-Toure’s study, the main reasons for vaccine hesitancy among healthcare service users in Abidjan were fear of side effects, vaccine ineffective ness, rumours and denial of the disease [11].

Factors associated with acceptance of mandatory vaccina tion

Occupational status (OR=1.26; P=0.001), particularly mem bership of the medical professions, was one of the factors as sociated with acceptance of the vaccination requirement. This fact, frequently observed among healthcare personnel, could be explained by the more in-depth knowledge acquired during medical training on vaccination, but also on vaccine-prevent able infectious diseases and immunity.

Paradoxically, not receiving training in vaccinology (OR=1.73; P=0.02) predisposed respondents to accept mandatory vaccina tion. It may be that in-depth knowledge of all aspects of vaccin ology influences healthcare workers’ behaviour in demanding greater freedom in the use of vaccines. They understand that vaccination is far from being a trivial or insignificant interven tion, but rather one worthy of interest, to be embraced freely, not out of obligation. Indeed, without the need for coercion, those trained in vaccinology have better knowledge and better vaccination practices than those who are not trained. [8]

Having a vaccination record (OR=0.81; P˂0.001) was a factor associated with acceptance of mandatory vaccination among respondents. This document is the best reflection of their com mitment to and practice of vaccination as a means of preven tion for themselves. Mandatory vaccination would simply be in line with their opinion on vaccination.

Lastly, hearing about mandatory vaccination for healthcare workers (OR=1.87; P˂0.001) increased acceptance of manda tory vaccination among our respondents. As there is no vacci nation requirement in Côte d’Ivoire, these healthcare workers probably had information about vaccination elsewhere in the world. This highlights the importance of scientific communica tion and exchange in understanding that a measure already in place and beneficial in some countries could also be beneficial in our context.

Limitations

During our work, we benefited from good collaboration with doctors and all staff, despite their busy schedules. However, our non-probabilistic sampling method could lead to selection bias and limit the extrapolation of results to all healthcare workers in Côte d’Ivoire.

Vaccinating healthcare workers is very important due to the risk of infection they face in the course of their work. The major ity of healthcare workers agreed to mandatory vaccination, but many of their vaccinations were not up to date. There are still barriers to vaccinating healthcare workers, which can only be overcome by placing a strong emphasis on training and provid ing appropriate information.

Conflicts of interest

Authors declare no conflicts of interest.

Contributions of authors

Harvey ATTOH-TOURE and Audrey ABINA developed the study protocol; Audrey ABINA, Roland OUSSOU, Edwige AYE VA-ADAM and Vatrai GNEBA collected and analysed the data; Harvey ATTOH-TOURE, Audrey ABINA and Soualihou NOUFE in terpreted the data; Harvey ATTOH-TOURE, Audrey ABINA and Roland OUSSOU wrote the manuscript; Konan N’GUESSAN and Simplice DAGNAN reviewed it; All authors reviewed and ap proved the final version of the manuscript.