Development and validation of COVID-19 vaccination perception (CoVaP) instrument among healthcare workers in Malaysia

Introduction

The coronavirus disease 2019 (COVID-19) has caused a substantive impact on social, psychological, economic and health aspects, as well as global mortality (Bandyopadhyay et al., 2020). The healthcare workers (HCWs) are one of the vulnerable group to be affected psychologically, due to work related stress (Hamdan et al., 2023). The catastrophic consequences associated with the COVID-19 pandemic have accelerated the process of COVID-19 vaccination at an unimaginable speed to keep the outbreaks under control. The COVID-19 vaccination has substantially altered the course of the pandemic, saving tens of millions of lives globally and safeguarding economies from continued disruption and damage (Watson et al., 2022).

Currently, the COVID-19 disease has reached a post-pandemic stage and two public health issues have arisen: there is a risk of a new strain emerging and causing another major catastrophic outbreak and the current burden of COVID-19 infection needs effective preventive measures (Watson et al., 2022). COVID-19 vaccination remains an effective measure to control this disease and has significant benefits despite the emergence of new variants (Kitano et al., 2023). Nevertheless, the rapid development of vaccines, the emergence of new variants, and the dissemination of misinformation relating to the risk of vaccination and policy changes fueled by digital platforms have promoted COVID-19 vaccine hesitancy globally (Larson, Gakidou & Murray, 2022).

Vaccine hesitancy is defined as people who delay or refuse vaccination despite its availability, reject or postpone certain vaccines, refuse all vaccines, and accept but remain concerned with it (Edwards & Hackell, 2016; MacDonald, 2015). The Strategic Advisory Group of Experts (SAGE) on Immunization describe vaccine hesitancy as a behaviour shaped by factors including confidence, complacency, and convenience. Confidence refers to trust in the vaccine and the provider, complacency involves the perceived need or value of the vaccine, and convenience covers accessibility and logistical concerns (Larson et al., 2014).

COVID-19 vaccine hesitancy is influenced by a complex interplay of psychological, social, and contextual factors, which have been systematically analyzed using theoretical frameworks such as the 5C model (Rancher et al., 2023), the 7C model (Araujo-Chaveron et al., 2024), the vaccine hesitancy scale (VHS) (Akel et al., 2021), and the vaccine conspiracy beliefs scale (VCBS) (Al-Sanafi & Sallam, 2021). The 5C model identifies five key factors: confidence, complacency, constraints, calculation, and collective responsibility (Rancher et al., 2023). The 7C model expands on this by adding compliance and conspiracy. Geiger et al. (2022) and the vaccine hesitancy scale (VHS) measures hesitancy through dimensions like lack of confidence and perceived risks (Shapiro et al., 2018). The vaccine conspiracy beliefs scale (VCBS) assesses the impact of conspiracy beliefs on vaccine acceptance (Al-Sanafi & Sallam, 2021).

These models provide a structured approach to understanding the determinants of hesitancy, including trust in vaccines, perceived risks, misinformation, and sociodemographic influences. These frameworks were widely applied to assess vaccination attitudes across diverse populations, including HCWs. For example, studies using the 5C model revealed that socio-demographic characteristics and drivers of vaccine behaviour, such as high levels of trust and collective responsibility, were key drivers of acceptance among the general public in South Carolina (Rancher et al., 2023). The 7C model showed that compliance and conspiracy beliefs were critical in understanding vaccine hesitancy among healthcare workers, parents, and adolescents in France (Oudin Doglioni et al., 2023). The VHS highlighted that younger age and women were among the factors associated with low vaccine confidence among the general public in Israel (Grossman-Giron et al., 2023). The VCBS model demonstrated that higher levels of conspiracy beliefs were associated with lower vaccine uptake in Poland (Kowalska-Duplaga & Duplaga, 2023). These insights helped tailor public health interventions to address specific concerns and improve vaccination rates across different demographics.

The impact of vaccine hesitancy is expected to be greater and pertinent to public health, particularly when involving vulnerable frontline groups such as healthcare workers (HCWs). HCWs played a crucial role in the COVID-19 vaccination campaign by improving health literacy, recommending vaccination, and mitigating the spread of the virus. They were pivotal in educating the public about vaccine safety and efficacy, enhancing health literacy and addressing vaccine hesitancy. HCWs’ recommendations significantly increased vaccination rates, as patients were more likely to get vaccinated when advised by their healthcare providers. However, they also posed a risk of transmitting the virus to vulnerable groups, highlighting the importance of their vaccination. Additionally, increased absenteeism among healthcare workers due to illness or quarantine impacts healthcare services. Studies have shown that healthcare workers (HCWs) were a critical group for vaccination studies due to their high exposure risk and their role in influencing public health behaviours (Blake et al., 2024; Hoffman et al., 2022). Therefore, it is crucial to improve the HCWs’ confidence in the vaccine before engaging them in promoting vaccination (Saddik et al., 2022).

An extensive umbrella review of studies conducted among HCWs and healthcare students in 2023 found that vaccine hesitancy was mainly influenced by sociodemographic factors (like gender, age, and ethnicity), occupational factors (such as COVID-19 exposure and perceived risk), health factors (including vaccination history), vaccine-related concerns (about safety, efficacy, and side effects), social factors (like social pressure and collective responsibility), distrust (in key social actors and pandemic management), and information factors (such as inadequate information and exposure to misinformation (McCready et al., 2023). There were numerous studies regarding the hesitancy, perceptions, and attitudes of HCWs toward COVID-19 vaccine (McCready et al., 2023). However, the available tools specifically validated for HCWs are relatively lacking. Most scales were validated for the general public (Campo-Arias, Caamaño Rocha & Pedrozo-Pupo, 2023; Guad et al., 2021; Mejia et al., 2021; Reznik et al., 2021). A few validated scales were conducted for the HCWs. These include coronaphobia scale in Mexico (Mora-Magaña et al., 2022), corona anxiety scale in Turky (Evren et al., 2022), and COVID19 stigma scale in Syria (Al Houri et al., 2022). Most of the studies were done during the pandemic and outside Malaysia, which has different cultures, and norms. Malaysia is often described as a “multicultural country” due to its diverse population, which consists of multiple ethnic, cultural, and religious groups coexisting within the same nation. The main ethnic groups in Malaysia are Malay, Chinese and Indians. The multicultural nature of Malaysia plays a significant role in shaping public attitudes and behaviours, including vaccine hesitancy. For example, some Muslims in Malaysia expressed concerns about the halal status of COVID-19 vaccines (Ismail et al., 2023). Trust in the government and healthcare systems varies across ethnic groups. Historical experiences and perceived discrimination can affect how different communities view vaccination campaigns. Understanding and addressing these multicultural factors is crucial for designing effective public health campaigns to overcome vaccine hesitancy and ensure broad vaccine coverage in Malaysia.

Malaysia began its vaccination program in February 2021, prioritising high-risk groups such as healthcare workers, the elderly, and individuals with comorbidities. By mid-2022, the country had achieved high vaccination coverage, with over 80% of the total population fully vaccinated and a significant portion receiving booster doses. Malaysia has not implemented a nationwide mandatory COVID-19 vaccination policy for the general population. However, vaccination has been strongly encouraged through various incentives, such as allowing vaccinated individuals greater freedom of movement and access to public spaces during lockdowns. For certain sectors, such as healthcare and education, vaccination has been effectively mandatory. The COVID-19 vaccines are provided free of charge to all Malaysian citizens and non-citizens residing in the country. Malaysia’s COVID-19 Vaccination Programme included administering a range of vaccines such as Pfizer (Comirnaty), AstraZeneca (Vaxzevria), and Sinovac (CoronaVac), depending on availability and suitability for different population groups The government has borne the cost of vaccination as part of its National COVID-19 Immunization Program (PICK), which aims to achieve herd immunity and reduce the burden on the healthcare system (Hamdan, Fahrni & Lazzarino, 2022).

Malaysia has reported relatively high COVID-19 vaccine acceptance rates among its general population. Surveys conducted during the initial vaccine rollout indicated that approximately 80–90% of Malaysians were willing to be vaccinated. Kalok et al. (2023), Syed Alwi et al. (2021) and a recent survey in 2024 indicated that the COVID-19 acceptance rate was 56.5% (Mohd Anuar et al., 2024). However, COVID-19 booster vaccination rates in Malaysia remain below 50% among the general public (Khoo et al., 2024). In Malaysia, specific data on vaccine hesitancy among HCWs is limited, making it challenging to fully understand the barriers to vaccine uptake within this critical group. A cross-sectional study involving 380 HCWs at a tertiary hospital in Malaysia during the early phase of the pandemic reported low vaccine hesitancy (Mahmud et al., 2023).

This study aims to develop and validate an instrument for assessing the perceptions towards COVID−19 vaccination (CoVaP) in the Malay language specifically for Malaysian HCWs. Accurate and reliable assessment tailored to this population is needed to capture the unique cultural and contextual factors influencing vaccine perceptions in Malaysia, helps design interventions specifically addressing healthcare workers’ concerns, informs policymakers and healthcare administrators for effective program design and enables tracking of vaccine hesitancy trends over time.

Materials and Methods

The development and validation of the instrument were conducted in two distinct phases, ensuring a comprehensive approach to creating a reliable and valid tool. The method for the development and validation of the instrument followed the practices advocated in the previous reports (Ostromohov et al., 2022; Tsang, Royse & Terkawi, 2017). Data were collected as previously described in Zaid et al. (2024).

Results

CFA

The mean (SD) age of the respondents was 37.3 (8.4) years and 76.7% was female. About 34% were nursing staff and 38% were in administrative positions. The CFA analysis showed that the model achieved acceptable fitness index values, indicating good model fit. The RMSEA of the model (0.011) indicated adequate fit and the goodness of fit index (GFI), CFI, TLI and the normed fit index (NFI) showed a good fit (0.987, 0.999, 0.999 and 0.987, respectively). The Chisq/df was less than 3, indicating adequate fit and acceptable value. Hence, the final CoVaP contained seven items with two factors, as illustrated in Fig. 1.

Discussion

HCWs have a significant role in promoting vaccination and can influence patient or public vaccination uptake. Therefore, it is crucial to improve their confidence in vaccination and engage them in activities targeting vaccine hesitancy among their patients. Therefore, continuous monitoring of vaccine perception among the HCWs is pertinent to a successful vaccination program and safeguards the healthcare system. There is a rapid and tremendous growth of literature regarding COVID-19 vaccine hesitancy and acceptance in HCWs globally, leading to the need to update the community and government on these issues. Many studies have been conducted on the perceptions of COVID-19 vaccination using various instruments, but it has not been validated properly (Fares et al., 2021; Mejia et al., 2021; Sirait et al., 2024). Hence, this study aimed to develop and perform a detailed validation of an instrument that can evaluate the perceptions of the COVID-19 vaccine among HCWs in Malaysia. Fortunately, this will help bridge the gap, as the findings might be valuable for other studies.

The CoVaP instrument demonstrated high content and face validity, with item-level content validity index (I-CVI) scores ranging from 0.83 to 1.0 and a scale-level content validity index (S-CVI/Ave) of 0.97. Similarly, the face validity indices (I-FVI and S-FVI/Ave) were also high, indicating that the items were relevant, clear, and comprehensible to the target population. These findings suggest that the CoVaP instrument is well-suited for assessing HCWs’ perceptions of COVID-19 vaccination. EFA and CFA supported a two-factor model comprising seven items, categorized into two domains: efficacy and safety (ES) and misinformation and trust issues (MT).

Interestingly, the items that were developed, especially based on the occupational risk of HCWs, were removed during the analysis, probably indicating that the perceptions of HCWs regarding the COVID-19 vaccine were similar to those of the general public (Wong et al., 2023). This indicates that most HCWs in Malaysia did not perceive that the occupational risk of getting COVID-19 infection is an important issue, nor do they believe that they must take the vaccine due to occupational risk. These results must be interpreted carefully, and further studies are needed to explore this issue. Undermining the issue of occupational risk among HCWs is very important to safeguard preventive measures in future pandemics. There could be several variables contributing to this, such as their lack of involvement in the clinical setting or their pre-existing mindset of being more susceptible to contracting infections in the community than clinical work. Therefore, it is advisable for healthcare facility management to consistently disseminate information about the high susceptibility of HCWs to COVID-19 infection due to the nature of their job.

Domain efficacy and safety (ES) consists of items related to confidence in the vaccine and risk calculation aspect. This domain consists of items on “I believe the COVID-19 vaccine is safe because it has been clinically tested.”, “I feel the effectiveness of the vaccine outweighs the risk of serious side effects” and “I think this vaccine protects us from the severe complications of COVID-19 infection”. These results demonstrated that the 5C model theoretical framework can be used to explain the perceptions of HCWs in this study, and this model has been used extensively in studies on the perception of COVID-19 vaccination (Rancher et al., 2023). The 5C model postulates five level determinants of vaccine hesitancy: confidence, complacency, constraints, risk calculation, and collective responsibility (Nuwarda et al., 2022). Confidence refers to trust in the vaccine’s safety and efficacy; complacency relates to perceptions of the infection as a danger and whether vaccination is required; constraints include structural and psychological barriers related to vaccination intention and uptake; risk calculation refers to comparing the risk of infection versus immunization. Finally, collective responsibility involves the desire and willingness to become vaccinated to protect others or to generate herd immunity (Rancher et al., 2023).

While trust issues about vaccine safety and efficacy were significant predictors of hesitancy globally (McCready et al., 2023), CoVaP results suggest that Malaysian HCWs showed higher vaccine confidence and low risk of infection (risk calculation). The item related to distrust in the severe side effect reports issued by the Malaysian Ministry of Health was removed during the analysis. This is probably because the HCWs in Malaysia have better access to real-world efficacy data and trust in the authorities. This highlights the importance of local trust in government policies, setting the Malaysian context apart from findings in Western studies, where individual autonomy and lack of trust in the vaccine, vaccine producers, or the government often shaped the barriers to the COVID-19 vaccination (Goodwin et al., 2022; Rancher et al., 2023).

However, the items for religious issues, vaccine-containing electronic chips and using complementary medicines to protect against COVID-19 infection were similar to other studies conducted among HCWs (McCready et al., 2023). Malaysia is a multi-religious country with a diverse population that practices various faiths, and Muslims constitute the majority of the population. Thus, religious issue also plays an important factor in shaping the perception of vaccines among HCWs. This was similar to studies conducted in countries that are predominantly Muslim (Abu Farha et al., 2021; Fares et al., 2021) and also other studies in Malaysia (Lau et al., 2021; Syed Alwi et al. 2021). Understanding these factors is essential for designing effective public health interventions to address vaccine hesitancy and improve vaccination rates.

The CoVaP instrument has demonstrated robust psychometric properties for assessing HCWs’ perceptions of COVID-19 vaccination. Given its strong content and construct validity, as well as its reliability, there is potential for this instrument to be adapted for use with other vaccines and in different epidemic contexts. The CoVaP instrument’s core domains—efficacy and safety (ES) and misinformation and trust issues (MT)—encompass fundamental aspects of vaccine acceptance and hesitancy that are not specific to COVID-19. For instance, concerns about the efficacy and safety of vaccines are universal and apply to any vaccination campaign. The items in the CoVaP instrument that address these concerns can be easily adapted to assess perceptions of other vaccines, such as those for influenza, measles, or HPV. Misinformation and trust issues are common barriers to vaccine acceptance across different diseases. The CoVaP instrument’s items related to misinformation and trust can be modified to reflect the specific context of other vaccines, making it a versatile tool for assessing vaccine perceptions. During various epidemics, the rapid development and deployment of vaccines often lead to similar challenges in public perception. By changing the items to reflect the particular disease and vaccine in issue, the CoVaP instrument can be modified to meet these situations.

There are several limitations in our investigation. The study respondents were chosen via chain-referral sampling, which introduces the possibility of selection bias. However, this method is to ensure that the anonymity and privacy of the respondents are carefully safeguarded. This is done because the topic is considered a sensitive issue and may influence the working environment of the respondents. Hence, the research was conducted not using official channels. Test-retest reliability was not conducted in this study due to time constraints. We used different time frames and contact resources for EFA and CFA data collection to safeguard that those HCWs in the EFA and CFA are different. Besides, we also restricted the Google Form to be filled out once only. However, we could not control the outcomes since they may be repetitive to the findings.

Moreover, our study encompassed HCWs employed across diverse units within public and private healthcare facilities, an aspect that has yet to be extensively investigated in Malaysia. This study’s research subject is contemporary and significant, although it has yet to get much attention in Malaysia. Despite these constraints, the study answers the question. Therefore, the findings may be utilized as a source of information for developing interventional strategies that aim to reduce vaccine hesitancy and increase vaccination rates among healthcare workers, who are the gatekeepers in the healthcare system. Consequently, this can significantly impact the efforts to prevent and control COVID-19 inside the nation.

Supplemental Information