key: cord-1000712-nwvkql6l
authors: Caiazzo, V.; Stimpfel, A. Witkoski
title: “‘Vaccine Hesitancy in American Healthcare Workers During the COVID-19 Vaccine Roll Out: An Integrative Review”
date: 2022-04-01
journal: Public Health
DOI: 10.1016/j.puhe.2022.03.017
sha: 3e448046a1bcd5618fcb947b7c42e6cf30f35b6b
doc_id: 1000712
cord_uid: nwvkql6l

Objective The purpose of this integrative review is to examine the literature on vaccine hesitancy among American healthcare workers during the COVID-19 vaccine roll out. Methods A review of quantitative literature on acceptance, intention, refusal or hesitation to accept the COVID-19 vaccine was conducted, searching in PubMed, CINAHL, PsycInfo, and Web of Science. Due to the immediacy of the topic research letters were included in addition to articles. The 18 publications were appraised for quality using the Critical Appraisal Checklist for Cross-Sectional Studies by the Center for Evidence Based Management. Results Estimates of vaccine hesitancy among healthcare workers was similar to the general population. The literature indicates demographic characteristics associated with vaccine hesitancy, including being younger, female, Black, Hispanic or Latinx. However, examination of the demographic data also points to gaps in the understanding and implications of those characteristics. The newness or perceived rush of vaccine development and implementation were the most cited sources for hesitancy. Conclusion The studies in this review give clear areas of need for translational research on dissemination and implementation relating to the correlational data, including in areas of comorbid, diasporic, and reproductive health concerns. However, with the gravity of the pandemic and quick arrival of the COVID-19 vaccine happening in the midst of an infodemic, adjunctive interventions could be warranted to combat hesitancy.

For over two years healthcare workers (HCWs) around the globe have been providing care and services during the COVID-19 pandemic, putting themselves at an increased risk for contracting the potentially deadly disease. [1] [2] [3] [4] [5] In the same month that the battle against COVID-19 began, the U.S. Department of Health and Human Services issued a statement about accelerating the development and production of vaccines under Operation Warp Speed (OWS). 6 OWS had the distinct goal of speed without sacrificing safety. Development was synergized by large funding streams, previous MERS, SARS and RNA vaccine research, the ability of researchers to run multiple trials, and advances in manufacturing. 7 The goal of OWS was subsequently attained within the first year of the pandemic by two vaccines granted emergency use authorization (EUA) by the Food and Drug Administration on December 11, 2020. [8] [9] [10] [11] Eight days prior to the EUAs, the CDC's Advisory Committee on Immunization Practices recommended that HCWs be among the first Americans offered vaccination under the emergency use authorizations (EUA) citing "early protection of healthcare personnel is critical". 12 Approximately 17.5 million Americans belong to this category 13 and, have become subject to vaccination mandates.

General population hesitancy regarding the COVID-19 vaccine has been correlated with being female, Black, and younger. Additional correlates could include lower educational attainment, rural or geographic residence, prior vaccination hesitancy, and lower perceived risk of COVID-19. [14] [15] [16] [17] [18] [19] Further, a perceived rush over vaccine development and approval, as well as concerns over safety and efficacy has plagued public health campaigns. 14, 16, 18, 19 Saliently, the spread of mis-and dis-information, culminating in an infodemic, has underscored the COVID- 19 pandemic and vaccine development. 20, 21 America has seen a relatively large distribution of J o u r n a l P r e -p r o o f misleading or false information surround the pandemic and vaccine roll out, and over a third of mis-or dis-information regarding the COVID-19 vaccine was related to vaccine development during the year of the roll out. 22, 23 The unprecedented nature of the virus and subsequent vaccine development, as well as the nature of the infodemic in which it has been unfolding, differentiates COVID-19 vaccine hesitancy from vaccine hesitancy around long standing vaccines. Yet, despite the differences in context vaccines remain the most effective way to curb the spread of infectious disease. With so many Americans employed in the healthcare sector, implications for COVID-19 spread among healthcare workers, their patients and communities at large are substantial. Thus, the purpose of this integrative review is to synthesize and examine the quantitative literature specific to HCWs hesitancy surrounding the roll out of the COVID-19

vaccine.

This review was guided by Whittemore and Knafl (2005) 

Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 24, 25 Critical appraisal was conducted with the Critical Appraisal Checklist for Cross-Sectional Studies 26 (Table 1 ).

The literature search was conducted in July 2021 using Cumulative Index for Nursing and Allied Health Literature (CINAHL) via EBSCO, Medline via PubMed, Web of Science, PsychInfo. Databases were searched for "COVID-19 vaccine", and alternate terms of "Coronavirus" and "Sars-CoV-2", paired with keywords such as "acceptance", "intention", "hesitancy", "attitude", "uptake", "confidence", and "refusal". Relevant search terms for the population of interest, "healthcare workers", included "health personnel", "healthcare provider", "health professional", and "nurse". Truncation was used when possible.

J o u r n a l P r e -p r o o f Inclusion criteria was left purposely broad as to include all types of HCWs and facilities.

Data collection conducted on American HCWs in or after 2020 was the primary inclusion criteria based on the U.S.'s unique social and healthcare landscape. The American pandemic response, which included OWS and timely access to vaccines, focused on HCWs as a primary class of vaccine recipients. Letters were included based on the immediacy of the topic, offering comprehensive coverage as data was emergent. A total of 1,533 records were obtained. After duplicate removal, 922 citations were screened and 28 went to full text review and 18 are included in this review ( Figure 1 ).

Of the 18 studies, 11 were peer-reviewed articles 27-37 and 7 were research letters. [38] [39] [40] [41] [42] [43] [44] All 18 published data from cross-sectional surveys collected over short periods on participants gained from nonprobability sampling frames. All studies gave a snapshot of vaccination acceptance or intention and refusal or hesitancy among their sample. Correlational trends were most often given as odds ratios. Most asked additional questions, but less than half the publications reported using trialed or validated questionnaires. Surveys included reasons for hesitancy, and safety or efficacy perceptions.

The largest sample size was 16,292 participants 42 , the smallest 81 27 and the median 1,600. 40, 44 The shortest study was 3 days in length 37 , with most completed in two weeks to a month. An exception was Halbrook et al. 31 , with data collected at three time points from September 2020 to February 2021. Of the studies reporting response rates, the lowest was 10% 28 and the highest was 82%. 29 The oldest data collection was done in August 2020 34 and seven collected data in December of 2021, the month of the EAUs [29] [30] [31] [32] 35, 40, 42 (Table 2 ).

The publications included a total sample population of 62,728 HCWs. Two articles focused on specific occupational roles of medical doctors 27 or nurses. 30 Apart from those exceptions occupational totals were reported too diversely to synthesize effectively. One study was conducted in long-term care facility 37 and two in community-based care settings. 29, 43 The remaining 16 were conducted entirely in, or included, hospital settings. Eleven studies were multi-site [29] [30] [31] 33, 34, [36] [37] [38] [39] [40] 44 , with three being multi-state. 33, 36, 44 Over half of the study populations came from the Northeast, however, all regions of the United States were represented.

Of the studies that reported on gender (N=46,279) 75.8% of those sampled were female.

Three studies 27 Age was reported in a variety of ways, except for the two letters in which age was not reported. 42, 43 Two articles 33, 35 reported mean age of participants as 40 and 42.5, respectively. The J o u r n a l P r e -p r o o f majority of participants' age (N= 26,357) was reported by two articles 32, 37 and two letters 40, 41 using a cut off of 40 years. Participants were almost evenly distributed with 51% being younger than 40, 45.3% older than 40 and 3.7% of data unreported (Table 3) .

Overall, 68.8% (N= 42,284) of the sample population indicated they had or would receive a COVID-19 vaccine. Almost half the studies [28] [29] [30] 33, 34, 36, 37, 39 included an option for future vaccination intention, ranging from specific timeframes (e.g., within 30 days) to simply "sometime in the future" or to "wait and see". Acceptance or immediate intention ranged in studies from 33% to 95%, with a median of approximately 63%. Those that either reported they would or did refuse or, if given the option, were unsure they would get the vaccine, was 31.2% (N=19,199). If separated out 18.8% refused and 12.4% were unsure. If separating out positive intention, 15%, of those given the option, reported wanting to wait for vaccination. The number of missing or not reported answers for the total sample was 1,245 or approximately 2%.

Data stratified by EUA date exhibit temporal variations in intention ( Figure 2 ). Out of studies with data collection prior to the EAU month of December 2020 (N=16,467), 77.3% of the sample reports positive intention, 19.1% refusing, and 3.6% of the data is not reported. Of the data collected during the month of the EUA (N=36,902) 59.9% reported positive intention while 37.7% were unsure or refusing and 2.4% of the data unreported. For the data collected after the EUA month, (N=11,075) 73.6% reported vaccination, 1.2% had positive intentions for future vaccination, 15.7% refused and 3.9% were unsure, with 5.6% of the sample was unreported.

Data stratified by EUA date may indicate positive intention was at its lowest, both in the crude and adjusted ratios, during EUA passages in December.

The majority of correlational findings associated sociodemographic characteristics with vaccine hesitancy, namely gender, race/ethnicity, age, and education while other factors such as safety, perceived risk and prior vaccination were also explored. Eleven studies compared gender with vaccine hesitancy and found that females had greater hesitancy than males 28, 29, [31] [32] [33] [34] [35] [36] [37] [38] 41 , with two studies also referencing lower intent than non-binary counterparts. 33, 35 However, Halbrook et al. 31 noted that while females had higher levels of hesitation, they actually had statistically significantly higher rates of vaccination acceptance than their male counterparts.

Thirteen studies reported on the correlations of hesitancy with race and/or ethnicity 28, 29, [31] [32] [33] [34] [35] [36] [37] [39] [40] [41] 44 The majority cited more hesitancy among Black and/or Hispanic participants compared to their white counterparts. The data were split on hesitancy among Asian participants with three studies reporting higher hesitancy 31, 39, 40 and four reporting less hesitancy 28, 32, 35, 36 than their white counterparts. Ten studies examined correlations of age. 28, [32] [33] [34] [35] [36] [37] [38] [39] 41 Two of the ten reported no statistically significant differences 34, 41 , while the other eight associated younger age with more hesitancy.

Out of six articles that explored education, five [31] [32] [33] [34] 36 affirmed that lower educational status correlated with higher hesitancy. Studies reporting on occupations of physicians, or advanced practice providers, correlated the roles with lower rates of hesitation or refusal. 28, 29, 35, 39, 44 Notably in the study of 8,243 long-term care staff, nurses were found to be more hesitant than nursing aides by 5 percentage points and Ciardi et al. 28 found nurses and patient care associates to have the most hesitancy by profession.

Perceived risk was discussed in two ways: perceived occupational risk (exposure to infected patients) and perceived personal risk of infection (including comorbidities, self-reported health status or concern over COVID-19 severity). Nine articles reported on perceived risk in some sense, however, the results were mixed. [28] [29] [30] [32] [33] [34] [35] [36] 41 Three articles, comprising of 20,800 participants almost all from the Northeast (83%), reported that providing patient care correlated with higher hesitancy. 32, 35, 36 Two articles of small sample size, varied location and setting type reported perceived lower risk was statistically significantly associated with more hesitancy. 29, 33 Parente et al. 34 found no statistically significant difference between vaccine acceptance and providing patient care or self-reported health in their study of 3,347 workers. While Kocioleck et al. 41 reported low levels of perceived risk, as well as having self-reported high risk medical conditions were correlated with more hesitancy in their midwestern sample (N=4,277). Similarly, Kuter et al. 32 found that self-reported poor/fair health status correlated with higher hesitancy (N= 12,034).

Twelve articles reported on safety concerns over vaccination within their samples. 30, [32] [33] [34] [35] [36] [37] [39] [40] [41] [42] 44 Safety concerns ranged from the rapidity of development to adverse reactions, long term side effects, and efficacy. Additional issues around politicization of the vaccines, and/or a lack of trust in or transparency by the government or companies making the vaccines was reported by six publications. 33, 36, 37, 39, 40, 42 The most frequently cited reasons for hesitancy or refusal appeared to be the newness or perceived rush of development, and EUA, as well as the potential for side effects.

Four articles examined prior vaccination status and concurred prior hesitancy or refusal correlated with hesitancy or refusal of COVID-19 vaccination. 28, 32, 34, 36 Two studies reported on geographic differences found those living in rural areas had more hesitancy. 32, 36 

The findings of this review reflected a group of timely publications regarding the COVID-19 vaccination roll out with a particularly at-risk occupational group, healthcare J o u r n a l P r e -p r o o f workers. Overall, we found that estimates of vaccine hesitancy among healthcare workers was similar to the general population. Demographic characteristics associated with vaccine hesitancy, included being younger, female, Black, Hispanic or Latinx, however, examination of the demographic data also points to gaps in the understanding and implications of those characteristics. Further, the newness or perceived rush of vaccine development and implementation were the most cited sources for hesitancy.

The urgency to disseminate data on the topic is demonstrated by the number of letters included, despite their inability to provide rigorous details as articles can. As all samples were convenience, and one was a snowball, all had the potential for selection or response bias and constraints on generalizability due to their nonprobability sampling structures. Over-or underrepresentation of responder subgroups, including by vaccination status or intentionality may influence the robustness or magnitude of observed correlations. Overall, no study adequately addressed sample size justification and three studies included information on their reference population and just one study tried to categorize and account for non-response bias (Table 1) .

Further, lack of standardization is apparent in the data reporting above.

On the surface, the data presented from the 17 studies in this review echo the trends observed in the U.S. adult population citing higher hesitancy among those that are female, younger, Black or Hispanic/Latinx. However, how race and ethnicity is reported, and how studies manage missing data, may alter the reporting of resulting correlations 45 . Within the overall sample, race and ethnicity had the highest rate of undisclosed data out of the variables. The divergence of data regarding Asian participant's hesitancy may be related to more granular details regarding country of origin. Such data is necessary when Filipino nurses make up roughly four percent of the nursing workforce and share a disproportionate amount of J o u r n a l P r e -p r o o f COVID-19 cases and death, along with their Black counterparts. 46 Further, no research included information on foreign born workers, who currently make up 4.1 million workers in the healthcare and social assistance industry. 47 Additionally, the lack of female specific concerns as well as the role nursing could play in the vaccine discourse should also be examined. The data upheld that females have greater hesitancy, however, Halbrook et al. 31 posits that they then have a higher rate of vaccination acceptance. Ciardi et al. 28 posits in the discussion that intention is lower for women of any age, which questions the importance of fertility and childbearing in vaccine decision making. Out of the post vaccine roll out literature, Pamplona et al. 43 was the only publication to report on the discrete variables of pregnancy or breastfeeding. Meyer et al. 42 included pregnancy or breastfeeding and Schrading et al. 44 included pregnancy and fertility as reasons for hesitancy, but this was reported vaguely in figure and table formats, not in text. Given that over 70% of the healthcare worker population is female, and over half of childbearing age, lack of this data warrants future study.

It is noteworthy that the clinical trials of vaccines did not include pregnant or lactating women. 48 However, all major reproductive health organizations recommend pregnant women receive the vaccine. 49 Since HCWs are majority female, these concerns must be included in the discourse, even if to rule out their influence. This may be even more salient as concerns over vaccine development and approvals was indicated as a primary reason for hesitancy, especially within the female population.

Similarly, nursing is predominantly female, the largest sector of the healthcare industry at roughly four million workers, and consistently voted the most trusted profession. 50 ,51 Yet nursing is largely absent from the scholarly discourse around vaccination hesitancy. Only two J o u r n a l P r e -p r o o f publications had a nurse as lead author 30, 38 and an additional two disclosed having a nurse as a nonprimary author. 37, 41 Further, nurses have higher rates of hesitancy than their medical counterparts. In March of 2021, 30% of nurses had not been vaccinated. 52 Of those reporting refusals, half indicated concerns about information scarcity and, vaccine development and approvals. Currently, the American Nurses Association reports approximately 11% of nurses remain hesitant and 42% are against mandates. 53 As mandates are rising in prevalence, vaccination or termination laws have the potential to exacerbate staffing shortages 54 intention. 20, [61] [62] [63] In the climate of the pan-and info-demics, America is marching toward mandates as the Supreme Court upheld the Biden administration mandate for HCWs. 64 However, it is unclear if vaccination mandates will extend beyond a yearly requirement, including booster doses, how many HCWs would resign rather than be vaccinated or how many may be covered by J o u r n a l P r e -p r o o f religious or medical exemptions. The effects of mandates on HCW employment, and potentially worker shortages, may not be felt immediately.

Mandates may be seen as an efficient and socially just way to increase vaccination 65 and America is not alone in pursuing them, with other countries including Germany, France and Italy mandating HCW vaccination. 66, 67 Vaccination Injury Compensation Programs (VICP), are available in 16 European nations, Canada, and Australia, some regardless of COVID-19 vaccination mandates. 68 Given that fear of side effects was present in the literature as a source of hesitancy, such safeguards are justified and necessary. Currently the U.S. does have a VICP, however it has not been extended to COVID-19 vaccinations. The U.S. has a Countermeasure Injury Compensation Program, but it is not as expansive or easy to apply to as VICP. 69 An alternate to vaccine mandates could include use of PPE and testing measures;

however, under the current mandate employers are not required to pay for testing. This may target the vaccine hesitant as the additional cost of frequent testing could prove substantial and unsustainable. 69 Other adjunctive alternatives could be explored such as the use of spatial modeling to guide vaccination efforts through geographic targeting. 70 Specific targeting, based on correlational data may be further enhanced by the concept of nudging interventions, which may include incentives, reminders, and reframing information dissemination. 71, 72 Conclusion HCWs continue to battle the COVID-19 crisis and exhibit vaccination hesitancy.

Correlates of hesitancy among HCWs appear to mimic correlates found in the general population but additional areas of investigation could give further clarity to the complex nature of vaccine hesitancy. This review of the literature was impacted by the asynchronicity of data reporting, which made comparisons difficult and limited synthesis of information. The gravity of the J o u r n a l P r e -p r o o f pandemic and the quick arrival of the COVID-19 vaccine is happening concurrently with an infodemic, in which large amounts of mis-or dis-information is being spread, and to which HCWs may not be immune. Implications of findings may evolve as trends shift in vaccination and acceptance. The U.S. could look to policies of other nations as well as alternative interventions to combat hesitancy as an adjunct to mandates.

None sought.

This research was funded, in part, by the National Institute for Occupational Safety and Health grant #T42 OH 008422

None to declare.

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Clinical care staff, including nurse aides and nurses in clinical roles, were less likely than dietary, housekeeping, and administrative staff to report willingness to receive the vaccine Nurses providing direct clinical care were −5 percentage points less likely to indicate a willingness to take the vaccine than nurse aides or similar role Concerns about side effects was the primary reason for vaccine hesitancy (70%) other non-mutually exclusive reasons given were health concerns (34%), questioning the effectiveness (20%), and religious reasons (12%) Additionally, 23% of respondents provided other reasons they would be unwilling to receive the vaccine such as concerns it is "too new," a lack of trust, the need for more research, or it was too political J o u r n a l P r e -p r o o f