Four reasons for COVID-19 vaccine hesitancy among health care workers, and ways to counter them

The World Health Organization (WHO) has identified vaccine hesitancy as a leading global health threat.¹ Rejection of the COVID-19 vaccine lessens the probability of herd immunity and could extend the pandemic. Especially concerning is vaccine hesitancy among health care workers (HCWs), including doctors and nurses as well as those who deliver indirect care and services (aides, helpers, laboratory technicians, and even medical waste handlers).² Not only are HCWs at increased risk of contracting and transmitting disease, but they also have a potentially powerful influence on patient vaccination decisions. Vaccinated HCWs are more likely to recommend vaccination to others.³ Understanding and addressing HCWs vaccination attitudes is crucial to promoting COVID-19 vaccine acceptance and can provide important lessons for other infectious disease crises.

A survey in Israel indicated that the percentage of people who intended to obtain a COVID-19 vaccine was 78% among physicians, 61% among nurses, and 75% in the general population.⁴ Low acceptance rates were also observed among Hong Kong nurses in two studies, and in late 2020, only 36% of U.S. HCWs said they were willing to take the vaccine as soon as it became available (56% said they were not sure and would wait to review more data).^5-7 Among the general population, surveys indicate that the percentage of Americans who don’t intend to get vaccinated declined from September to December 2020 (from 38% to 32% in one survey  and 34% to 27% in another).^8,9 Although this is encouraging, achieving herd immunity may require a higher proportion of the population to be vaccinated.¹⁰ Many factors guide vaccine attitudes. The following are four reasons for HCW vaccine hesitancy, and ways to counter them.

1. Safety and efficacy concerns

While the COVID-19 vaccines are not yet fully approved for commercial use by the Food and Drug Administration (FDA), the FDA has issued Emergency Use Authorization (EUA) of several vaccines due to the public health emergency, based on data from clinical trials that included tens of thousands of participants.¹¹ Still, the condensed timeline in which the vaccines were developed and received EUA has raised safety and efficacy concerns for some HCWs.^4,7

However, there is evidence that vaccine data can help assuage these concerns. Among HCWs, knowledge of a specific vaccine increased their willingness to recommend that vaccine.³

For instance, concerns about the speed of COVID-19 vaccine development are often based on the mistaken belief that mRNA technology — used for the first two COVID-19 vaccines authorized in the U.S. — is entirely new. But the first successful use of mRNA technology in animals was reported more than 30 years ago, and tremendous mRNA advances have been made over the past decade.¹²

Government, public health agencies, and private health care systems can work together to provide accurate information about the vaccines to HCWs. The increased availability of vaccine safety and efficacy data may be a factor in the increased acceptance of the vaccine in recent months.

2. Preference for physiological immunity

Herd immunity can be achieved through vaccination or via previous infections, which eventually lead to natural or physiological immunity.^10,13 Some Israeli HCWs, as well as some Americans and Canadians in the general population, have expressed a preference for physiologic immunity, rather than obtaining immunity via vaccination.^4,14 Individuals who believe the seriousness of COVID-19 has been exaggerated perceive the risk of vaccination to be greater than the risk of infection.¹⁴

The difference in consequences between these two approaches to reaching herd immunity must be clearly communicated to HCWs who currently prefer physiologic immunity over vaccination. Achieving herd immunity through previous infection would take significantly longer, incurring an immense cost in health care resources, as well as lives.^10,13,15

There is evidence of greater vaccine acceptance among HCWs who have cared for hospitalized COVID-19 patients, presumably because of an accurate perception of the severity of the disease.^4,7 Discussions with clinicians who have had these experiences may convince vaccine-hesitant HCWs to get the shot.

3. Distrust in government and health organizations

A key factor in gaining acceptance of a new vaccine is trust. Media misinformation can cause public doubts about disease spread, prevention, lethality, and vaccine safety, and can promote mistrust of the government, policymakers, health authorities, and pharmaceutical companies.^3,16 Many members of the public, including HCWs, have been exposed to conspiracy theories (especially on social media) such as the claims that novel coronavirus was intentionally created by the government or that health organizations have exaggerated COVID-19’s lethality for pharmaceutical and political gain. Such misinformation calls into question authorities’ integrity and undermines efforts to increase COVID-19 vaccine uptake.^14,16

Early on in the pandemic, social media exposure and conservative media exposure were both correlated with higher levels of misinformation about the SARS-CoV-2 virus.¹⁶ Placing accurate information on social media with credible sources will help to counter this misinformation.

Direct messaging from other HCWs, whether in the capacity of personal physician or co-worker, may be especially effective in decreasing vaccine hesitancy. Americans generally have a high level of trust in their physician, and there is evidence that HCWs have greater trust in medical professionals prescribing the vaccine than in public authorities and government.^7,17

Simply delivering factual information, however, is inadequate. Confidence among HCWs can be heightened through discussion, eliciting their concerns, and involving them in vaccine recommendations.^{17, 18}

It is crucial to remember that language matters. Based on a nationwide poll from December 2020, the de Beaumont Foundation created a “cheat sheet” for language to improve COVID-19 vaccine confidence.¹⁹  Although it’s too late now, government officials might have engendered greater trust in the vaccine development and dissemination process by labeling it “Operation Due Diligence,” instead of “Operation Warp Speed.”¹⁴

4. Autonomy and personal freedom

HCWs and rural Americans report that a sense of personal freedom informs their attitudes toward the COVID-19 vaccines.^7,20 Clinicians are held to the standard of informed consent when recommending treatments to their patients, and while COVID-19 vaccination remains elective, it is understandable that HCWs prefer to make their own choices about it.³

Motivational interviewing may increase the effectiveness of pro-vaccine messages in these instances.¹⁸ In a post-partum intervention to promote vaccination, the use of motivational interviewing increased infant vaccination rates by 9%.²¹ While research in motivational interviewing has focused on patients rather than on HCWs, there is little reason to believe that HCWs would respond differently than the general population. When HCWs feel their opinion is heard and valued, perhaps they will be more inclined to consider vaccine acceptance a personal choice rather than coercion.

Although not typically used in medical communication, emotional appeal may be a valid tool to complement other facets of vaccine education in both public health education campaigns and personal interactions among HCWs. Emotion can be leveraged in vaccination messaging by acknowledging negative emotions such as fear and anxiety, taking care to not heighten such emotions, and activating positive emotions such as hope and altruism (e.g., protecting one’s community from COVID-19).²² The emotional allure of anti-vaccine disinformation campaigns should also be examined so they can be countered with effective pro-vaccine messages.²³

Self-identity has been associated with beliefs regarding COVID-19 vaccination.^20,23 Exploring and understanding identity barriers is key to avoiding the reinforcement of vaccine-averse identities.²³ Narrative (versus logical-scientific) forms of communicating are intrinsically persuasive and offer options for countering vaccine hesitancy.^23,24 Equally important is creating narratives that allow changed opinion without losing face.²³

In summary

HCWs bridge the gap between health care policymakers and patients and have a disproportionate influence on patients’ vaccine decisions. Vaccination rates among HCWs correlate positively with their willingness to recommend COVID-19 vaccination to their patients.^3,7

Delays in COVID-19 vaccination among HCWs and the general population further prevent herd immunity and will result in increased COVID-19-related illness and deaths, creating a surge in the utilization of already strained health care resources.¹⁵

Broad uptake of the COVID-19 vaccine will be essential to reducing COVID-19 infections and deaths. Targeted messaging to HCWs, and using accurate messages delivered by trusted individuals, can increase uptake. Innovative ways to communicate information should be explored and employed to increase understanding of the empirical evidence underpinning public health officials’ endorsement of widespread COVID-19 vaccination.

—   Kehinde Eniola, MD, MPH, and Jean Sykes, MPH, PhD, RDN, Family Medicine Department, Cone Health System

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