key: cord-0699485-3ju7pifb authors: Dennis, A.; Robin, C.; Jones, L.; Carter, H. title: Exploring Vaccine Hesitancy in Care Home Employees in North West England: A Qualitative Study date: 2021-08-30 journal: nan DOI: 10.1101/2021.08.20.21262101 sha: ac9039e6e782ff3cc6f810a8612919738bd0559b doc_id: 699485 cord_uid: 3ju7pifb Objectives: Care homes have experienced a high number of COVID-19 outbreaks, and it is therefore important for care home employees to receive the COVID-19 vaccine. However, there is vaccine hesitancy at a greater rate among this group than in the wider community. We aimed to understand barriers and facilitators to getting the COVID-19 vaccine, as well as views on potential mandatory vaccination policies. Design: Semi-structured interviews. Setting: Care home employees in North West England. Interviews conducted in April 2021. Participants: 10 care home employees (aged 25 to 61 years old) in the North West, who had been invited to have, but had not yet received, the COVID-19 vaccine. Results: We analysed the interviews using a framework analysis. Our analysis identified eight themes: perceived risk of COVID-19, efficacy of the vaccine, concerns about the vaccine, mistrust in authorities, facilitators to getting the vaccine, views on potential mandatory COVID-19 vaccination policies, negative experiences of care work during the COVID-19 pandemic, and communication challenges. Conclusions: The care home employees interviewed at the time of this study reported a low perceived risk of COVID-19, alongside concerns over the efficacy of the vaccine, side effects, and speed of vaccine development, which is exacerbated by mistrust in authorities. Facilitators to getting the vaccine included wanting to protect others, perceived severity of COVID-19, and workplace norms. Making COVID-19 vaccination a condition of deployment may not result in increased willingness to get the COVID-19 vaccination, with most care home employees in this study favouring leaving their job rather than getting vaccinated. At a time when many of the workers already had negative experiences of care work during the pandemic due to perceived negative judgment from others and a perceived lack of support facing care home employees, policies that require vaccination as a condition of deployment were not positively received. The COVID-19 pandemic, caused by the spread of SARS-CoV-2, has led to substantial mortality and strain on health and care systems. One population most at risk of COVID-19 is care home residents and employees. Care homes have been disproportionately affected by COVID-19, with high rates of illness and death among care home residents, particularly in the first wave of the pandemic. Investigations into local outbreaks revealed that in April 2020, 21% of care home workers tested positive for COVID-19 [1] , and 31.1% of deaths in the first wave occurred in care home residents [2] . In some regions over a third of care homes have experienced an outbreak [3] . In 2020, several vaccines were developed that were shown to be effective and safe [4] , reducing both hospitalisation and mortality [5] . Consequently, several COVID-19 vaccines were authorised for use in multiple countries including the UK [6] . It has been estimated between 55% to 85% of populations would need to be vaccinated in order to reach herd immunity for COVID-19, depending on infection rates within each country [7, 8] . When England commenced COVID-19 vaccination rollout on the 8 th December 2020, care home residents and employees were in the first priority group to receive the vaccine. By 15 th February 2021, all care home residents and employees had been offered their first dose of COVID-19 vaccine. However, some care homes saw low COVID-19 vaccine uptake among employees. As of the 29 th April 2021, 94.8% of eligible care home residents and 81.0% of eligible care home employees had received their first COVID-19 vaccination [9] . Vaccine uptake among care home employees differs regionally, with the North East and South West having vaccine uptake above 84%, and the North West and London having vaccine uptake below 79%. In some areas in the North West reported vaccine uptake amongst care home employees is much lower, for example, a recent survey of care home staff in VACCINE HESITANCY IN CARE HOME EMPLOYEES Liverpool identified vaccination uptake was at 51.4% [10] . Therefore, it is important to understand reasons behind the lower vaccination uptake among some care home employees. Research has identified several barriers to getting the COVID-19 vaccine, including mistrust in healthcare professionals and scientists, safety concerns, negative perceptions of vaccination side effects, lower perceived threat of COVID-19, and inconsistent information [11] [12] [13] [14] [15] . Barriers for care home employees include perceived lack of research, concerns over fertility, concerns over allergic reactions, and difficulty accessing vaccination appointments [10] , with similar barriers also being identified among healthcare workers [16] . Despite these barriers, a recent meta-analysis of 40 studies found 61% of all healthcare workers agreed with mandatory vaccines, although vaccinated healthcare workers were more likely to favour mandatory vaccine than unvaccinated healthcare workers [17] . Care home employees are at a higher risk of contracting COVID-19 but are also a population with lower COVID-19 vaccination uptake. On 14 th June 2021, the UK government announced it would be a condition of deployment for care home employees working in older adult care homes in England to receive COVID-19 vaccination, and they would have 16 weeks to do this [18] . In the current study, we explored barriers to COVID-19 vaccination uptake among care home employees, including perceptions of mandatory vaccination (prior to the announcement COVID-19 vaccine would become a condition of deployment for care home employees). We used a qualitative method that allows for in-depth exploration of personal experience [19] and provides rich detail on feelings and experiences behind attitudes [20] . The current study had three aims. First, to identify reasons underlying care home employee decisions to decline COVID-19 vaccination. Second, to explore any factors that . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 30, 2021 Ten participants took part, aged 25-61 years old, see Table 1 for demographics. Participants were invited to take part in the study if they worked in a care home and had decided not to get their COVID-19 vaccination. Participants were recruited by contacting Health Protection leads for the North West, who then used snowballing sampling to identify local authorities who would be willing to assist with recruitment. The lead researcher then contacted the engaged local authorities and the four that agreed to help contacted care homes in their region and passed on the recruitment information. Participants then opted-in to the study by contacting the lead researcher using the details provided. All participants received a £20 voucher for taking part. There was no patient or public involvement. We developed the interview schedule through discussions based on prior knowledge and existing research [21] . The interview schedule centred around three main topics. First, barriers and facilitators to getting COVID-19 vaccination when offered. Second, sources of information about COVID-19 vaccination. Third, views on mandatory vaccinations. Openended questions and prompts guided the interviews to develop a conversational style to elicit rich descriptions [22] . Potential participants contacted the researcher and were given a copy of the information sheet. In some cases, details of potential participants were provided by care homes or local authorities and the information sheet was sent to them directly. Participants were sent an online survey to provide informed consent and basic demographic information. The first author conducted all interviews, which took place online during April 2021, before the announcement of potential mandatory vaccination for care home employees. Interviews ranged between 26 and 65 minutes and each interview was recorded and later transcribed. We analysed the data using framework analysis as it is grounded in data, flexible, and has been used widely to inform policy [23] . Using NVivo, the five steps of framework analysis were applied to the data [24] . In step one, interview transcripts were read; this familiarisation was then used to inform step two whereby the researcher identified codes in the data that related to the research questions, which included barriers to getting COVID-19 vaccine. Indexing was then carried out, whereby data were identified that related to broad themes which were then discussed with other members of the research group. Step four . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted August 30, 2021. ; https://doi.org/10.1101/2021.08.20.21262101 doi: medRxiv preprint VACCINE HESITANCY IN CARE HOME EMPLOYEES involved charting the data by summarising it into an analytic framework. All transcripts were coded by the lead researcher, with 30% double-coded by a second researcher to ensure consistency. The team then met to discuss the charted data, which led to the final themes. In the final step, themes were defined and clarified in relation to other themes. On completion of the analysis, no new themes emerged from the data and data saturation had been reached [25, 26] . Eight main themes were identified: perceived risk of COVID-19, efficacy of the vaccine, concerns about the vaccine, mistrust in authorities, facilitators to getting the vaccine, views on mandatory vaccinations, negative experiences of care work during the COVID-19 pandemic, and communication challenges. An overview of the themes and sub-themes is presented in Table 2 . . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The perception COVID-19 would not cause a severe illness either in general or specifically to participants. Low perceived likelihood of contracting COVID-19 The perception they were not at a high risk of contracting COVID-19. Contracting and transmitting COVID-19 The concern the vaccine may not be effective at stopping people contracting or transmitting COVID-19. The concern the vaccine may not be effective against future variants and this may lead to needing another vaccine. The belief the vaccine would have serious implications on health, such as fertility and blood clots. The concern the vaccine has been developed too quickly. The inconvenience of side effects The belief the vaccine will lead to minor side effects causing an inconvenience, such as needing a day off work. Mistrust in authorities in reporting COVID-19 statistics and in the vaccine rollout. Getting the Vaccine The view the vaccine is important to reduce the transmission of COVID-19 and protecting vulnerable individuals. The belief that at points during the pandemic COVID-19 was serious and this would have led them to get the vaccine. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted August 30, 2021. ; https://doi.org/10.1101/2021.08.20.21262101 doi: medRxiv preprint The perception of being one of a few in their care homes who have not received the vaccine. Importance of free choice The view mandatory vaccines would stop individuals being able to make their own decision about the vaccine. Willingness to get the vaccine if it was mandatory The willingness to get the vaccine if it was mandatory in care homes: some participants reported they would quit, and others said they would unwillingly get it as they need their job. Experiences of Care Work During The COVID-19 Pandemic The belief that the hard work of care home employees during the pandemic had been forgotten and not acknowledged. The feeling of judgement due to working in a care home generally, and judgement towards care home employees during the pandemic, for example for not having the vaccine. Lack of support from local authorities The belief local authorities had not provided adequate support to care homes during the pandemic and particularly during outbreaks at care homes. Participants views on the risk of COVID-19 were centred around the severity of COVID-19 and the likelihood of contracting COVID-19. Many participants perceived the severity of COVID-19 to be low and thought the risk had "I know the pros of having the vaccine outweigh the risk, but are you willing to take that risk when the chances of even getting COVID and having a bad reaction to it are low anyway" (Participant 6). However, it was acknowledged that if they had underlying health conditions, they would be more likely to get the vaccine: "if I had any illness or ongoing issues such as . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 30, 2021. ; https://doi.org/10.1101/2021.08.20.21262101 doi: medRxiv preprint VACCINE HESITANCY IN CARE HOME EMPLOYEES asthma, COPD, or like I was at a certain age category, I would have taken it" (Participant 10). The participants who had not contracted COVID-19 perceived their risk of catching it as low. Participants' concerns about the efficacy of the vaccine centred around two different subthemes: efficacy of the vaccine for preventing people from contracting and transmitting COVID-19, and the anticipation additional vaccines would be required to protect against variants. Several participants felt the COVID-19 vaccine would not be effective. The reasons given for this were a belief the COVID-19 vaccine does not lower the chances of transmitting COVID-19: "it doesn't stop from spreading it anyway" (Participant 2), and that more time is needed to understand how effective the vaccine will be: "at the minute we're not even 100% sure the vaccine is gonna work […] We'll only really find out end of this year, if it's worked or not" . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 30, 2021. ; https://doi.org/10.1101/2021.08.20.21262101 doi: medRxiv preprint Another concern for participants was the different variants of the COVID-19 virus. All participants mentioned concerns about the COVID-19 vaccine, which influenced their decision not to be vaccinated. These concerns could be broadly grouped into three subthemes: serious health risks associated with the vaccine, the speed of vaccine development, and the inconvenience of side effects. One of the key barriers was concern about the serious health risks the vaccine may cause: "it's just the health risks that is a concern for me" (Participant 9). One participant mentioned their allergy causing them to be at greater risk of experiencing adverse effects: "I am anaphylactic and I know originally the Pfizer one was deemed anyone anaphylactic […] to postpone getting the vaccine […] that's another no from me" (Participant 6). This theme links with perceived severity of COVID-19, participants mentioned that for them, health risks posed by the vaccine outweighed any risk of contracting COVID-19: "the risks for me with . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Participants' beliefs about health risks associated with the COVID-19 vaccine were drawn from two main sources. First, the health risks of the vaccine were influenced through family experiences of getting the vaccine: "My mum had the vaccine she was more unwell from that than COVID. She was in hospital, she was really unwell, but she was not that A lot of participants expressed concern about the speed with which the COVID-19 vaccine has been developed and rolled out: "I'm just not comfortable with the fact it's only just been developed" (Participant 5). The speed of development had led to mistrust in the vaccine rollout, specifically in the testing surrounding the vaccine. In addition, some participants expressed hesitancy about getting vaccinated because they wanted to wait for further testing of the vaccine to be done. This linked with wanting the vaccine in future, when further testing had been completed. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Alongside concerns about serious health risks, another concern was the inconvenient side effects of the COVID-19 vaccine that did not pose a serious threat to health, but rather were unpleasant or inconvenient. Some participants mentioned side effects their family or friends experienced after receiving the vaccine: "I can't think of anyone who hasn't had side effects from it" (Participants 4). Additionally, one participant explained they were concerned about the side effects as they did not want to get ill and take time off work: "I won't take time off work" (Participant 3). Participants expressed a lack of trust in authorities that contributed to their hesitancy in Although participants did not get the vaccine, they did mention reasons to get the vaccine. These facilitators were wanting to protect others, the severity of COVID-19, and workplace norms. The main reason participants thought they should get the vaccine was to protect others and reduce COVID-19 transmission. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The final reason why participants thought they should get the vaccine was because they perceived COVID-19 to be serious, which was particularly relevant at the beginning of the pandemic. Interviewer: "Are there any reasons you've thought you should get the vaccine?" Participant 1: "Right at the beginning when we started hearing about COVID, and it was killing people, people were dying from COVID, that was a concern because it was like, oh, hang on a second." When participants perceived COVID-19 to be severe they would have been more likely to accept the COVID-19 vaccine to prevent severe consequences. There was a workplace norm of getting the COVID-19 vaccine and participants who did not get it were in the minority: "the majority of people I work with have had it, yes" (Participant 7). In some instances, this workplace norm did influence them to book their appointment but did not lead to them getting the vaccine. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 30, 2021. ; https://doi.org/10.1101/2021.08.20.21262101 doi: medRxiv preprint Participants' views about mandatory vaccination could be grouped into two main subthemes: the importance of free choice; and willingness to take a mandatory vaccination for work purposes. There were several reasons why participants felt mandatory vaccination was inappropriate. First, making vaccines mandatory would cause a perceived lack of transparency: "people can make the decision for themselves on the benefits to risks ratio and people weren't given the opportunity to do that, so I think there's been a real lack of transparency and that's a concern" (Participant 5). Second, because it would prevent those who had not been vaccinated from certain freedoms: "I feel that it's terrible that you might not be able to do things because you've not had the vaccine" (Participant 9). Last, that it would be a betrayal of care home employees who have worked in care for years. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 30, 2021. ; https://doi.org/10.1101/2021.08.20.21262101 doi: medRxiv preprint All participants expressed their anger towards the possibility of vaccines being mandatory among care home employees: "I'd be absolutely livid … I think that would be disgusting" Participants generally reported negative experiences of working in a care home during the pandemic, with sub-themes including: feeling forgotten; experiencing judgement from others; and a lack of support from local authorities. There was a strong sense of feeling forgotten and underappreciation of care home employees during the pandemic: "Like I thought we might have been given something because we've had to work through the pandemic, but we literally received nothing in that way" (Participant 10). Participants felt that while the efforts of NHS staff had been recognised, they had been forgotten. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 30, 2021 However, many participants reported not just feeling forgotten, but experiencing negative Participants described how they felt they had been let down by local authorities during the COVID-19 pandemic. The lack of support by local authorities was highlighted during COVID-19 outbreaks at care homes: "it (COVID- 19) got in and once it got in we had no help from our local council" (Participant 8). It was believed that the support could have been . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 30, 2021 As a result of these negative experiences, some participants expressed a desire to leave their profession: "Oh yes. I'm currently looking for a new job" (Participant 9). It was also mentioned that other employees in their care home were looking for new jobs as well: "Quite a lot of the staff at the home that I currently work at are considering leaving, it's not public knowledge, but in various different homes a lot of staff are thinking of leaving" (Participant 8). Some participants discussed areas for improvement in communication, including communication from their employer, and ability to communicate openly with colleagues. Participants expressed mixed opinions on whether they needed more information from their employers. Some participants wanted more information about the vaccine, particularly in relation to safety concerns. "I think definitely there needs to be more information out there for women who are thinking of fertility is their fertility at risk if they do have the vaccine." (Participant 8) "if the vaccine is causing the blood clots that's my main concern […] they said it wasn't related and that it wasn't to do with it and then said that it was but the chances were very small and then in the next sense they are saying that we are no longer offering it to people under 30." (Participant 9) Other participants felt they had received too much information: "too much information, it depends where the information is coming from, at the moment I think there is enough information out there" (Participant 3), and that more information would be unlikely . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 30, 2021. ; https://doi.org/10.1101/2021.08.20.21262101 doi: medRxiv preprint VACCINE HESITANCY IN CARE HOME EMPLOYEES to encourage them to get the vaccine: "I think more information isn't going to change my mind at the moment" (Participant 3). Additionally, some believed the information they had received from their employer was one-sided and needed to be more honest: "have to show people the good and the bad but it was a very one sided view point, I don't think she put any negatives in there" (Participant 6). Some participants felt unable to talk honestly with colleagues about their views on getting the vaccine. Others were banned from discussing the vaccine at work for fear of persuading others not to get it. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 30, 2021. ; https://doi.org/10.1101/2021.08.20.21262101 doi: medRxiv preprint In this study, we explored care home employees' attitudes and behaviours towards the COVID-19 vaccine. Specifically, we examined barriers and facilitators to vaccine uptake and attitudes towards mandatory vaccines. It has since been made a condition of deployment for all staff working in older adult care homes in England to receive both COVID-19 vaccinations [18] . The results from this study therefore provide a timely and important understanding of some attitudes towards and possible consequences of a mandatory vaccination policy, as well as identifying barriers and facilitators to uptake of COVID-19 vaccines. The first aim of this study was to understand barriers to care home employees getting This led to participants perceiving the risk of having the vaccine (i.e. side effects) as outweighing the benefits (in terms of protecting them from COVID-19). In-line with this, participants stated that if they had an underlying health condition, they would be more likely to get the vaccine due to the increased risk of COVID-19. This is consistent with previous research where individuals with low perceived risk of COVID-19 have increased vaccine hesitancy [14] , as they feel less threatened by the disease and thus have less motivation to engage in more preventive behaviour [27] . Care home employees also questioned the efficacy of the vaccine for reducing the risk of transmitting and contracting future variants of COVID-19; as well as the safety of the . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 30, 2021. ; https://doi.org/10.1101/2021.08.20.21262101 doi: medRxiv preprint VACCINE HESITANCY IN CARE HOME EMPLOYEES vaccine, with concerns around the health risks; the speed of development and the inconvenience of side effects. These concerns over the safety of the vaccine were heightened by media reports and the negative experiences of others. Previous research [10, 11] has highlighted concerns over lack of research and a perception vaccine development had been rushed, as reasons for people not getting a COVID-19 vaccine. Participants in the current study reported they would consider getting the vaccine in the future once they perceived it to be effective and safe. This supports previous research, which identifies concerns over lack of research and speed of development as being common reasons for individuals to delay getting their COVID-19 vaccine [16] . Mistrust in authorities contributed to increased concerns about the safety of the vaccine and led to lower perceptions of COVID-19 risk. A lack of trust in the authorities involved in the vaccine response, and in the perceived efficacy and safety of the vaccine, all contribute to a lack of confidence in the vaccine [28] ; in turn, lower confidence in the vaccine predicts reduced intentions to get the COVID-19 vaccine [29] . In Liverpool, care home managers have attempted to address COVID-19 vaccine hesitancy through information and myth busting about the vaccine and educational material [10] . However, in this study, care home employees reported not engaging with the information as they felt it was either too much information, not balanced information, or it did not address their specific concerns. Care home employees wanted to discuss the vaccine in an open and honest way where both risk and benefits are acknowledged. Studies have shown providing too much information or unbalanced information can increase vaccine hesitancy [30, 31] . The second aim of the current study was understanding facilitators to care home employees getting a COVID-19 vaccine. Reasons given for potentially getting the vaccine included . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) [29] . Some participants highlighted there were times during the pandemic when they perceived COVID-19 to be more serious and as a result would have had the vaccine had it been available. The final facilitator was workplace norms. Most participants reported there was a workplace norm associated with getting the COVID-19 vaccine, and that they were one of few in their workplace who had not received the vaccine. The final aim of this study was to explore care home employees' attitudes towards mandatory vaccinations. All participants were strongly opposed to mandatory vaccines, with the media reports in early April 2021 about making the COVID-19 vaccination a condition of deployment for care home workers having a negative impact on participants' attitudes towards the vaccine. The strong opposition to such policies resulted from a perception that care home workers were not being allowed to make individual health-based decisions based on their own risks. Several participants also believed these types of policies were a betrayal of care home employees who they felt had worked tirelessly during the pandemic with little reward. The lack of acknowledgement and a feeling of being forgotten was frequently raised by participants, who felt they had faced judgement from the public and the media, and a lack of support from local authorities. In response to the possible requirement for care home employees to receive COVID-19 vaccination as a condition of deployment, some participants stated they would leave their job rather than getting the vaccine, whereas others stated they would unwillingly get vaccinated as they need their job. This is in line with previous research that shows the majority of vaccine hesitant individuals do not approve a mandatory policy for the COVID-19 vaccine [32] . Additionally, mandating vaccines can increase anger and . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) [33] [34] [35] [36] , and potential stigmatisation of those who refuse to have the vaccine [37] . Based on the findings from this study there are several recommendations that can be made. This study is based on findings from a fairly small number of interviews (n=10) with care home employees in the North West of England. While data saturation was reached, the small sample size should be noted and considered alongside the findings presented. Additionally, . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Where care home employees did identify reasons for getting the vaccine, these included wanting to protect others, severity of COVID-19, and workplace norms. Finally, all participants expressed negative attitudes towards mandatory COVID-19 vaccines, with mandatory vaccination potentially resulting in some care home employees choosing to leave their jobs and increasing negative experiences of working during the pandemic. Public Health England (PHE) Research Ethics and Governance Group (REGG) exempted this study from requiring ethical approval because the study involved . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted August 30, 2021. ; https://doi.org/10.1101/2021.08.20.21262101 doi: medRxiv preprint VACCINE HESITANCY IN CARE HOME EMPLOYEES interviewing care home workers in their professional capacity. No identifiable information was collected, and all participants opted into the study and provided informed consent prior to participation. Transcripts from the current study are available from the corresponding author on reasonable request. No competing interests. This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. All authors contributed to the design of the study. AD conducted all interviews and data analysis; CR assisted with data analysis. AD wrote the paper with CR, LJ, and HC all commented, read, and approved the final manuscript. We are grateful for the local authorities in the North West who aided with the recruitment for this study. Amelia Dennis https://orcid.org/0000-0002-9085-7432 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted August 30, 2021. ; https://doi.org/10.1101/2021.08.20.21262101 doi: medRxiv preprint High prevalence of SARS-CoV-2 antibodies in care homes affected by COVID-19: Prospective cohort study Second versus first wave of COVID-19 deaths: shifts in age distribution and in nursing home fatalities Evolution and effects of COVID-19 outbreaks in care homes: a population analysis in 189 care homes in one geographical region of the UK. The Lancet Healthy Longevity An mRNA vaccine against SARS-CoV-2-preliminary report Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK. The Medicines and Healthcare products Regulatory Agency. 2020. UK medicines regulator gives approval for first UK COVID-19 vaccine Herd immunity-estimating the level required to halt the COVID-19 epidemics in affected countries High contagiousness and rapid spread of severe acute respiratory syndrome coronavirus 2 NHS. COVID-19 weekly announced vaccinations 29 COVID-19 vaccine hesitancy in care home staff: a survey of Liverpool care homes. medRxiv [Preprint COVID-19 vaccine hesitancy in an ethnically diverse community: descriptive findings from the Born in Bradford study Psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the United Kingdom COVID-19 vaccination hesitancy in the United States: a rapid national assessment COVID-19 vaccine hesitancy in a representative working-age population in France: a survey experiment based on vaccine characteristics Factors associated with COVID-19 vaccine hesitancy Intention of nurses to accept coronavirus disease 2019 vaccination and change of intention to accept seasonal influenza vaccination during the coronavirus disease 2019 pandemic: A cross-sectional survey Healthcare Workers'(HCWs) attitudes towards mandatory influenza vaccination: A systematic review and meta-analysis Covid vaccine to be compulsory for England care home staff Integration or assimilation? Locating qualitative research in psychology Workshop synthesis: Measuring attitudes; quantitative and qualitative methods Vaccine hesitancy among healthcare workers in Europe: A qualitative study The experience and understanding of pain management in recently discharged adult trauma patients: A qualitative study Qualitative data analysis for applied policy research Qualitative Research Practice Are we there yet? Data saturation in qualitative research How many interviews are enough? An experiment with data saturation and variability Beyond confidence: Development of a measure assessing the 5C psychological antecedents of vaccination Vaccine hesitancy: Definition, scope and determinants Influenza vaccine uptake, COVID-19 vaccination intention and vaccine hesitancy among nurses: A survey Public Health Network: Optimizing communication material to address vaccine hesitancy Can the vaccine adverse event reporting system be used to increase vaccine acceptance and trust? Attitudes on voluntary and mandatory vaccination against COVID-19: Evidence from Germany Detrimental effects of introducing partial compulsory vaccination: experimental evidence The potential impact of vaccine passports on inclination to accept COVID-19 vaccinations in the United Kingdom: evidence from a large cross-sectional survey and modelling study. medRxiv Mandate vaccination with care