The Vaccine Blog

Vaccine hesitation / resistance among healthcare workers

Vaccination hesitation / resistance among healthcare workers


Disclaimer: Please note I am not a medical professional and am not an authority on the issue, I am expressing my own opinions in this article. This is not a substitute for medical advice. For accurate scientific information about vaccines, please visit the WHO website.


  • Introduction


Her vaccination stance put her livelihood on the line…


Brittany Watson is a nurse who previously worked at a hospital in Winchester. She applied for a religious exemption after her employer mandated the COVID 19 vaccine. She states that “I probably would have gotten it if it wasn`t such a push to get it”...”And then they mandate it. Now you`re telling me what to do. I`ve worked 18 months in the pandemic, and now I`m not allowed to work there if I don't have a vaccine.” Although she mentions later that religion factored in here, the feeling of being controlled is what comes across stronger.


Brittany`s case illustrates a clear theme among those who experience vaccination hesitation; regardless of the industry they are employed in - vaccination hesitation is not always about vaccines. In Brittany`s case, it was about freedom. Not just for herself, but about leaving a legacy of freedom for future generations. Does it condone placing many others at risk of infectious disease, and possibly spreading this perception to future generations? No. What it does do, however, is provide us with a clearer understanding of the reasons why certain groups of people experience hesitation about one or more vaccinations. This is a valuable insight when we`re talking about a group that has been shown through research to shape the vaccination perceptions of the public. They also regularly interact with immunocompromised individuals. These may include cancer patients, elderly individuals, and those on immunosuppressant medications.  Therefore, their perceptions can directly impact patient health outcomes.


If it isn't clear by now - I am of course talking about vaccination hesitation in healthcare workers (HCWs). 


  • Vaccination hesitation in physicians; an overview


For the reasons I mentioned at the end of the last paragraph among many others, this is a genuine concern due to the impact HCW attitudes and behaviors can have on patients. HCWs are the primary source of medical guidance for most people. They`re the people we trust in what is arguably our most vulnerable state (ie. when we`re ill). For instance, have you had cancer, an unplanned pregnancy, cancer or another health scare? Maybe you`ve had anxiety about an operation or another procedure? Who were you most reliant on? The point is; if healthcare workers experience vaccination hesitation, how can the public be blamed for having doubts? 


Thus, vaccine hesitation in physicians has the potential to cause significant impact on vaccination rates. Therefore, there are many questions to ask.  What percentage of healthcare workers experience vaccination hesitation? What percentage of healthcare workers refuse vaccines outright? - which is, importantly, an entirely different question. As with groups not working in the healthcare industry, trends in hesitation and refusal vary with time, place, and vaccine. For example, a 2023 study published by Mandeep Kaur investigated vaccination hesitation among healthcare workers in 15 European countries. According to the authors “Physicians’ average vaccination rate was 79% across a selection of vaccines, while that of nurses was 62%. Concerns regarding vaccine safety, information gaps, and the responsibility of healthcare authorities in managing VH are highlighted by qualitative insights.”  


  • Hesitancy about specific vaccinations in HCWs


However, what about specific vaccines among HCWs? What about HPV vaccination hesitation, for instance? Or COVID 19 vaccine hesitancy? ” In Israel, a 2019 study examined knowledge, attitudes and practices towards anti-HPV vaccination among pediatricians, gynecologists, and internal medicine physicians via an ad-hoc questionnaire. The authors found that, regarding HPV vaccine hesitancy, “Among Israeli pediatricians, gynecologists, and internal medicine doctors, knowledge was generally moderate, with updated information lacking in about 30% of surveyed health-care providers and approximately 20% of them not recommending the anti-HPV vaccine among boys. On the other hand, a good level of knowledge and positive attitudes towards recommending the anti-HPV vaccine significantly impacted parents' intention to vaccinate their children.” 


HPV vaccine hesitancy among healthcare workers was also studied among medical students in China in a 2022 study by Liangru Zu and colleagues. The authors examined prevalence and reported reasons for HPV vaccine hesitancy among Chinese medical students. Unfortunately, the authors reported, “a high degree of HPV vaccine hesitancy among the people surveyed, with more than 60% of the respondents reporting hesitancy about the HPV vaccine.” The key reported reasons for hesitancy were low perceived necessity of vaccination, stigma around sexual activity, convenience, and safety and effectiveness concerns. 


There is also significant literature on COVID 19 vaccine hesitancy in healthcare workers worldwide. For instance, a 2021 study on COVID 19 vaccine hesitancy in Ethiopian healthcare workers was conducted by Rihanna Mohammed and colleagues, The authors found a hesitancy rate of 60.9% in their study sample. Such COVID 19 vaccine hesitancy rates, they note, are similar to those in studies in southwestern Ethiopia. In Singapore, a 2022 study by Junjie Aw and colleagues examined hesitancy among community hospital staff. The authors found that “our paper adds to prevailing global evidence on how socio-demographic factors, younger age and female sex, specifically, are associated with COVID-19 vaccine hesitancy among healthcare workers” They note that this mirrors trends in other developed countries. This is especially evident in the early phase of the COVID 19 pandemic. 


Not only this, a 2023 study published by Suzan Joseph Kessy examined vaccine hesitancy among healthcare workers in Tanzania in East Africa.  In this case, COVID 19 vaccine hesitancy was reported by 62.5% of HCWs. The primary reasons were similar to other studies on HCWs, as well as in the general population. These included “potential side effects (68.9%), misinformation (11.0%), trust (12.2%), and the risk of contracting COVID‐19 from the vaccine (10.4%).”


A 2022 study conducted a similar investigation. The authors found reasons for hesitancy similar to those in the general population. Crucially, they note that “medical training and clinical experience do not remove HCWs from the same emotions and dilemmas that all members of the general population experience. Thus, despite their professional titles, concerns about vaccination should be acknowledged while simultaneously holding professionals to high standards.” This is important. There is a trend among these studies in the last 2 paragraphs. They highlight something that many people intuitively understand, but perhaps don't often articulate.


Health professionals are people before anything else. This applies to any individual in any profession. This means that they are all vulnerable to the same emotions that cause biases. If you follow my work, you`ll have read my articles on biases. You'll realize that all 7 billion people on the planet are subject to a list of biases. If you take nothing else away from this, take that away. So vaccination hesitation in this group is not necessarily a scientific thing. It's a human thing. It can be helpful to remember this when engaging with someone who is biased to such an extent that their acceptance of facts is clouded. Remember, we`re not debating the effectiveness of vaccines themselves here, there are hundreds of studies confirming their safety and effectiveness. It's not a debate. What is needed, however, is a discussion of how people develop perceptions that lead them to vaccination hesitation. The point is; it's not always about vaccinations themselves. 


  • Barriers and facilitators to vaccination in HCWs


With that, what are the barriers and facilitators to vaccination in healthcare workers? #


Evidently, a small proportion will have medical reasons not to take the covid 19 vaccine and possibly other vaccines. The criteria for obtaining a medical exemption are very narrow; making them quite difficult to obtain. Further, if one vaccine cannot be given due to pre-existing conditions, another vaccine type may be suitable. However, I`ll briefly discuss several medical reasons not to take the COVID 19 vaccine and other vaccines that apply to a small minority of people. 


According to the website of the World Health Organisation (WHO), “you should not be vaccinated if you have a history of severe allergic reactions/anaphylaxis to any of the ingredients of the COVID-19 vaccine, or if you have a fever over 38.5ºC on the day of your vaccine appointment. Postpone until you have recovered. If you are on blood thinners, it is safe for you to get vaccinated, but let the person vaccinating know.    


Other barriers to vaccination in HCWs are logistical including time, funds, and access. Some questions healthcare workers may ask themselves are similar to those the general public may have. Can they get time off work for vaccination, for instance.How much will it cost? Are childcare services available while parents are being vaccinated? Where is the nearest vaccination site? This is by no means a comprehensive list of questions. Also, some healthcare workers have unique circumstances that present barriers to vaccination. Living in remote areas, having rare health conditions, among many others, may add further difficulty.

Understanding of the importance of vaccinations is one barrier to vaccination that I'm slightly more reluctant to add here. The majority of biological and medically-focused degrees do cover vaccination from one perspective or another. This may be through the lens of immunology, microbiology, epidemiology or more than one of these. Therefore, the majority of healthcare professionals will have a knowledge base about vaccinations. However, as with everything there are outliers and this is unlikely to be an exception. 


It is important to note that this is not a comprehensive list of factors affecting the acceptance of COVID 19 vaccines and others in healthcare workers. Also,  such factors vary with time, place, and vaccine. They are dynamic, in other words. They may also interact in complex ways. For both of these reasons, no two people`s experiences of vaccination hesitation are the same. 

  • Strategies to overcome vaccine hesitancy among HCWs

With the issue more clearly defined, the next logical question is how to address it. Given that there is overlap in vaccine concerns between HCWs and the general public, it will not be surprising that there is a degree of overlap in strategies to address hesitancy in the two groups. 

For example, a 2023 “umbrella review” was conducted by Jemma Louise McCready and colleagues on vaccine hesitation in healthcare workers worldwide. They found that “vaccination programs and public health campaigns should tailor messages to reflect the variation in sociodemographic characteristics and the social and cultural norms surrounding the target group. The information and message delivered to the target group should be presented in a format that the target group can relate to and access.”


Further, acceptance rates of COVID 19 vaccination among healthcare workers were studied in a 2023 study in Lusaka in Zambia. This study was more reassuring, however still highlighted areas of concern. The authors found an 80.4% acceptance rate among physicians compared to an acceptance rate of 76.3% for nurses, 58.3% for pharmacists and only 55.6% for other HCWs. In terms of strategies, the authors discuss that there is  “an urgent need to increase educational activities among this critical group concerning the science of vaccines and their benefits in the fight against vaccine-preventable infectious diseases. Alongside this, any educational activities across Zambia should seek to increase awareness, knowledge and positive attitudes towards vaccinations.” 


The authors also emphasize the importance of ongoing educational interventions, and ongoing monitoring of the situation. As I've discussed before, factors associated with hesitancy are dynamic and vary over time. Therefore ongoing approaches will allow strategies to be adapted and refined over time. Taking their concerns seriously in this way will also help to build trust between healthcare professionals and health authorities. This in turn may encourage healthcare providers to issue strong, genuine vaccine recommendations to patients.  Both parties (that is, provider and patient) will also benefit from accurate information being disseminated in mass social media campaigns, which the authors of the study also recommend. 

I would add that another factor in these acceptance rates may be medical specialty. Consider a healthcare professional trained and experienced in vaccinations and infectious disease. They are likely to have more knowledge and understanding of vaccinations, and therefore more confidence in them. This is not to minimize the importance of other healthcare professionals having confidence in vaccinations. It is crucial. This is simply to highlight one factor of many that may contribute to vaccine acceptance, and how it could be a future avenue of research. With that said, tailored strategies could be developed for different specialties. 

  • Conclusion;


The key idea that stands out from research on HCWs and vaccination hesitation is that their concerns mirror those of the general population. They are human before anything else, as is anyone regardless of their job title. They are subject to the same emotions, fears, and biases as everyone else. This explains. the observations on COVID 19 vaccine hesitancy, HPV vaccine hesitancy and healthcare workers.  Factors affecting the acceptance of vaccines are complex and dynamic. However, they include medical reasons in a small minority, as well as convenience, low perceived disease risk, and safety and effectiveness concerns. Given that these overlap with concerns of the general population, it will not be surprising that strategies used to address hesitancy in HCWs and the public also have some degree of overlap. Tailored interventions by specialty, ongoing educational interventions and monitoring of the situation, and social media campaigns are noted as important strategies. Vaccines affect the lives of all 7 billion people on the planet. They always have since their discovery, and likely always will. Therefore it is impossible to have too many advocates, campaigns or interventions. Thanks for reading!

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  • References


  1. Judging 'sincerely held' religious belief is tricky for employers mandating vaccines : NPR
  2. Knowledge of Human Papillomavirus (HPV), Attitudes and Practices Towards Anti-HPV Vaccination Among Israeli Pediatricians, Gynecologists, and Internal Medicine Doctors: Development and Validation of an Ad Hoc Questionnaire - PMC
  3. HPV Vaccine Hesitancy Among Medical Students in China: A Multicenter Survey - PMC (
  4. COVID-19 vaccine hesitancy among Ethiopian healthcare workers - PMC
  5. Health care workers intention to accept COVID-19 vaccine and associated factors in southwestern Ethiopia, 2021 - PMC
  6. COVID-19-Related Vaccine Hesitancy among Community Hospitals’ Healthcare Workers in Singapore - PMC
  7. Converting the maybes: Crucial for a successful COVID-19 vaccination strategy - PMC
  8. Relationship between Citizens’ Health Engagement and Intention to Take the COVID-19 Vaccine in Italy: A Mediation Analysis - PMC
  9. Attitudes towards influenza vaccine and a potential COVID-19 vaccine in Italy and differences across occupational groups, September 2020 - PMC
  10. Mask usage, social distancing, racial, and gender correlates of COVID-19 vaccine intentions among adults in the US - PMC
  11. Vaccination willingness, vaccine hesitancy, and estimated coverage of SARS‐CoV‐2 vaccine among healthcare workers in Tanzania: A call for action - PMC (
  12. COVID-19 Vaccination Hesitancy among Healthcare Workers—A Review - PMC (
  13. COVID-19 vaccine hesitancy in Latin America and Africa: a scoping review - PMC (
  14. Vaccine Hesitancy among Healthcare Workers in Europe: A Systematic Review - PMC
  15. COVID-19 Vaccines Advice
  16. Understanding the barriers and facilitators of vaccine hesitancy towards the COVID-19 vaccine in healthcare workers and healthcare students worldwide: An Umbrella Review - PMC (
  17. COVID-19 Vaccine Acceptance and Hesitancy among Healthcare Workers in Lusaka, Zambia; Findings and Implications for the Future - PMC (