What makes healthcare workers vaccine hesitant?

Hesitancy has plagued the rollout of COVID-19 vaccinations all over the world.
 
In Australia, a number of factors, including the local spread of Delta and stringent public health measures that have kept loved ones apart, as well as sweeping vaccine mandates, have all contributed to the country now being on track to become one of the most vaccinated in the world.
 
But as mandates come into effect in preparation for eased restrictions, protests have yet to abate – and healthcare workers, albeit a minority, are among those voicing their concerns about what they perceive as the pressure to be vaccinated.
 
With the global COVID death toll having surpassed five million, and extensive data showing the benefits of vaccination far outweigh the risks for most, and the fact frontline healthcare workers are at increased risk of contracting and transmitting the virus, what is at the root of this hesitancy?  
 
One reason might be that, despite preconceived ideas about higher levels of education and health literacy, healthcare workers as a group are not inherently different from everyone else.
 
Dr Jane Williams is an APPRISE CRE research fellow at Sydney Health Ethics at Sydney University, specialising in public health ethics with an interest in infectious diseases. She told newsGP that healthcare workers essentially represent a microcosm of the general population, with similar demographic traits and concerns as others who are vaccine hesitant.
 
‘They’re concerned about safety, they’re not convinced about efficacy, and they’re worried about side effects,’ Dr Williams said.
 
Research funded by the Victorian Government confirmed this idea, with around 60% of both healthcare workers and the general public expressing concerns about long-term effects, and about 50% worried about serious adverse reactions.
 
The research also found that 78% of healthcare workers expressed an intention to be vaccinated, with men, older people and those living in metropolitan areas more likely to be vaccinated, which is again in line with the general public.
 
A study conducted in France revealed similar findings, with 73.1% of healthcare workers in favour of vaccination, 23.1% hesitant and 3.9% completely against it.
 
According to Associate Professor Holly Seale, a Social Scientist at the UNSW School of Population Health and Deputy Chair for the Collaboration on Social Science and Immunisation, there have always been false expectations about healthcare workers and their attitudes around immunisation.
 
‘Certainly we know we have a proportion of health workers who every year refuse to get the flu vaccine because of concerns around safety and effectiveness and so forth,’ Associate Professor Seale told newsGP.
 
‘There is a spectrum of knowledge around immunisation.
 
‘And these COVID vaccines have pushed out new terminology, they’ve pushed out new technology, so for many they’re still trying to wrap their head around all of the different vaccines that we have in play.
 
‘What is the latest safety data? What’s happening around boosters? It is hard to keep up with it.’
 
Recent protests in Australia have also revealed that hesitancy for some healthcare workers is, at least in part, tied to mandates and the threat their choice poses on their employment status and livelihood.
 
Adelaide nurse Deni Varnhagen was among the SA Health staff protesting mandatory vaccination earlier this month in Adelaide, holding a sign that read, ‘I love being a nurse. Coercion is not consent’.
 
John Edward Larter, who has been a paramedic for 25 years in NSW, took his concerns to the Supreme Court. Branding the mandate ‘morally repugnant’, Mr Larter was seeking a vaccine exemption on religious grounds, a request that was dismissed by the court this week.


Dr Jane Williams says there is vaccine hesitancy among healthcare workers as they represent a microcosm of the general population. 

For its part, the RACGP issued a position statement in September in favour of mandatory vaccination. President Dr Karen Price said the stance has not been taken lightly and highlighted doctors’ responsibility to look after not only themselves, but also their patients and staff.
 
‘Speaking personally, I simply cannot fathom how a healthcare worker – a person who has dedicated their life to protecting and helping patients – could argue that their right to remain unvaccinated is more important than the health and safety of vulnerable patients who could potentially die as a result of their decision,’ Dr Price wrote in a newsGP column.
 
An August newsGP poll found that, out of 4634 respondents, 35% did not agree with mandatory COVID vaccinations in the workplace and 7% believed it would only be suitable for particular settings with high risk of exposure.
 
Dr Williams said that while vaccine mandates in healthcare settings make sense for the most part, the fact general practices are owned and operated as private businesses is likely to affect some GPs’ views.
 
‘Having to stand down staff who aren’t vaccinated is potentially going to be a problem for their business,’ she said.
 
‘Also, because of precedents [set by] the flu vaccine, where it’s only mandatory for healthcare workers in certain settings, to me that just feels like a hangover of, “Well, this is what we’ve done before and that’s what is acceptable”.’
 
But the case of a practice nurse in Western Australia who allegedly faked administering a vaccine to a patient and then fraudulently recorded their vaccinated status, has raised some alarm regarding anti-vaxxers in the workplace.
 
Dr Williams says that while such acts are illegal and indefensible, it is important to differentiate between those acting fraudulently and those making decisions for themselves.
 
Are vaccine mandates ethical?
That is a complicated question, according to Dr Williams.
 
She says in some settings – such as healthcare – mandatory vaccination in a pandemic environment makes sense, but certain preconditions should be met first. This means giving people every opportunity to get vaccinated prior to a mandate being enforced.
 
‘It’s super important to point out that availability and access aren’t the same thing,’ Dr Williams said.
 
‘I mean offering it at the workplace if that’s possible [or] delivering vaccines at home. Giving paid time off to go and get vaccinated – this is particularly an issue for casual workers.
 
‘Making sure that there are information resources, including people they can talk to who they trust. There might be people also working the same job or who might be working and living in a certain community.
 
‘All of that has to be exhausted before you can mandate something.’
 
It is also crucial that people do not feel blindsided, which Dr Williams believes has been a problem in Australia.
 
‘I think we’ve jumped to mandates way too quickly,’ she said. ‘For example, the aged care announcement in June was completely inappropriate because a mandate was announced before people really had access to vaccination.
 
‘Somebody losing a job and not having an income is, depending on the industry that they work in, a disproportionate response.’
 
The potential impact on staffing levels must also be considered.
 
‘I do have some concern about what happens to staffing levels,’ Dr Williams said.
 
‘In British Columbia [Canada], 2% of all healthcare workers have been stood down due to not being vaccinated. Healthcare doesn’t have heaps of give in it, so 2% is really disruptive and can cause unintended harms beyond COVID.’
 
Where to from here?
Associate Professor Seale believes there is a real need to dig deeper to get a better understanding of exactly who the hesitant healthcare workers are, and what opportunities they have been given to address their concerns with their individual needs in mind.
 
Meanwhile, with Australia’s first booster program already underway, she says addressing logistics and how the program is run could also help address hesitancy among healthcare workers, particularly if vaccines can be offered in occupational settings.
 
‘That may be what we need to really focus on beyond just the thinking, feeling elements of whether or not staff want to get vaccinated,’ she said.
 
But in the immediate term, Dr Williams believes holding space for in-depth conversations that are free of judgement is vital.
 
‘It is important to just try to have respectful conversations. Try to understand why and try to counter that,’ she said.
 
‘And that is a difficult thing sometimes for people to do because they’re a bit like, “Oh for God’s sake, you’re a doctor, you should know better”.
 
‘That’s not useful in any sort of vaccine hesitancy, but probably more particularly for healthcare workers because they’re probably not feeling terribly well supported.’
 
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COVID-19 healthcare workers mandatory vaccination vaccine hesitancy