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Abstract

Background:

Although many Americans were anxious to see a vaccine developed to help restore a sense of normalcy to the COVID-19 pandemic, vaccine hesitancy is still a problem that hinders public health goals designed to stop the spread of the virus. With two mRNA vaccines available since early 2021 only 71% of Americans have received at least one dose of vaccine by November 30, 2021, with 60% of the population being fully vaccinated.

Methods:

This article discusses the risk factors of vaccine hesitancy, the factors influencing the unwillingness to accept vaccines approved and recognized as safe, characteristics of vaccine hesitancy among worker populations, and guidelines and resources for nurses.

Conclusions and Application to Practice:

The key for the nurse is to self-educate and proactively begin the discussion of vaccines with patients and co-workers, building trust with patients and peers, and helping motivate them to accept COVID-19 vaccines and make appointments to receive vaccinations. Overcoming the impact of low vaccination rates due to vaccine hesitancy is the first step toward closing the gap and achieving universal vaccination for all adults.

Keywords

COVID-19 vaccine hesitancy public health vaccine confidence vaccine acceptance

Background

In 2020, the first year of the COVID-19 pandemic, many Americans were anxious to see the development of a new vaccine to help restore a sense of normalcy to their everyday lives. In May of 2020 the 73rd World Health Assembly adopted a resolution that recognized and promoted vaccine development as a public health goal to stop the spread of the virus. The Pfizer/BioNTech and the Moderna vaccines (each a two-dose series) were announced and approved under an Emergency Use Authorization (EUA) in late 2020, whereas the Johnson & Johnson vaccine was announced and approved under an EUA in early 2021. The Pfizer vaccine was given final approval by the U.S. Food and Drug Administration (FDA) in August 2021 (U.S. FDA, 2021).

The first half of 2021 saw vaccination clinics emerge on a massive scale throughout the nation. As of November 30, 2021, 233,207,582 people (71%) of Americans have received at least one dose of vaccine, whereas 197,058,988 people (60%) were considered fully vaccinated (USAFacts.org, 2021). These numbers raise several questions, such as with all the publicity and attention given to COVID-19 vaccine development, why is the rate of vaccination not closer to 100%? Why are millions of Americans reluctant to get vaccinated? There are more than 125 vaccines under development, 365 trials now under study, and 18 vaccines approved world-wide, so why is there still a reluctance of so many to roll up their sleeves to help reduce infection rates? (Machingaidze & Wiysonge, 2021).

What Is Hesitancy?

MacDonald and the SAGE Working Group on Vaccine Hesitancy (MacDonald & The SAGE Working Group on Vaccine Hesitancy, 2015) explored the concept of hesitancy, noting that the term is not specifically well-defined but is described more as a continuum with those who accept vaccines on one end, a significant assortment of hesitant individuals in between, and the complete refusers on the other end. After much deliberation the SAGE Working Group agreed on this definition:

Vaccine hesitancy refers to delay in acceptance or refusal of vaccination despite availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place, and vaccines. It is influenced by factors such as complacency, convenience and confidence. (MacDonald & The SAGE Working Group on Vaccine Hesitancy, 2015)

Wiysonge et al. (2021) described vaccine hesitancy as an unwillingness to receive vaccines when services are accessible and available. Wiysonge et al. go on to describe how the World Health Organization (2020) refers to COVID-19 as not so much of an epidemic, as an infodemic—an excess of information. In the current environment of instant communications, consumers are flooded with a mix of information, correct and incorrect, that rapidly spreads like a virus, creating uncertainty in the population. This rapid spread of information creates confusion and doubt about the safety and efficacy of a vaccine, resulting in vaccine hesitancy. In addition, Wiysonge et al. (2021), Betsch et al. (2020), Machingaidze and Wiysonge (2021), and Betsch et al. (2018) described research from high-income countries suggesting five individual-level determinants comprising vaccine hesitancy: confidence (trust in efficacy and safety), complacency (the perception that risk of disease is low and a vaccine is not required), convenience/constraints (structural or psychological barriers to vaccination), risk calculation (a perception of higher risks from vaccination than from the disease), and collective responsibility (a willingness to protect others and promote population immunity).

The following are several factors among population sectors that may be influencing unwillingness to accept vaccines approved and recognized as safe. Machingaidze and Wiysonge (2021) mentioned the five drivers of vaccine hesitancy discussed above and described that health care professionals must assess and understand whether people are willing to be vaccinated, learn the reasons why they may be unwilling or willing, and discover the trusted sources of their decision-making process.

Once health care professionals assess and understand patient vaccine health beliefs and their individual determinants of health, they can begin the educational process necessary to address hesitancy. This article will examine several studies discussing factors related to vaccine hesitancy and provide the reader recently identified causes of hesitancy and offer tips to nurses on the best approach with these populations.

Vaccine Hesitancy Among Health Care Workers

A study was published in early 2021 by Paris et al. discussing results of a self-administered questionnaire (1,956 respondents out of 5,655 eligible) in France. Significant differences were noted among demographic groups. For instance, <60% of administrative staff intended to be vaccinated (staff, cleaners, auxiliary nurses, and technicians); whereas 60% to 79% of nurses, lab technicians, pharmacists, and other support staff and >80% of executives, residents, students, and medical staff intended to be vaccinated. In this survey the largest controversy centered on perceived adverse effects of the AstraZeneca vaccine causing a dramatic decrease in intention to vaccinate from 74.8% down to 58.3% (Paris et al., 2021; Raude, 2016). Paris et al. (2021) also noted a strong correlation between influenza and COVID-19 vaccine acceptance intentions. Significantly, the intention to receive COVID-19 vaccine was 46.4% in health care workers never vaccinated with influenza vaccine compared with 89.3% for those regularly accepting the influenza vaccine. Those never vaccinated with influenza vaccine were significantly more likely to reject the COVID-19 vaccine (odds ratio [OR] = 6.17; 95% confidence interval [CI] = [4.55, 8.37]).

In contrast, a report by Relias Media (2021) revealed that 20% of nurses refused the COVID-19 vaccine in the United States, whereas only 5% of doctors did. The major reasons given for the refusal were uncertainty about vaccine safety and efficacy, concerns for personal safety, and fears about the speedy approval process. Among the most hesitant groups were Black health care workers where 35% have not been vaccinated (Relias Media, 2021).

Paris et al. also found that the media and communications were a significant factor in affecting vaccine hesitancy. As noted by Paris et al. (2021) and Raude (2016), a few negative media events produced a significant increase in vaccine hesitancy in France, requiring a substantial effort for health providers and other officials to communicate the positive benefit balance of vaccines through all media, including social networks. The authors concluded that any negative or controversial news about vaccines can quickly increase vaccine hesitancy.

Vaccine Hesitancy Among In-Betweeners

A group of vaccine-hesitant persons not often examined are the In-Betweeners. Damian McNamara in September 2021 researched those who may have various reasons for not immediately accepting vaccines and do not wish to be labeled as “anti-vaxxers.” While the group has these two similarities, the reasons of their unwillingness, where they reside, and their individual characteristics are as varied as the nation is broad. McNamara quotes Dr. Walter A. Orenstein, Professor and Associate Director of the Emory Vaccine Center in Atlanta, this group as “people . . . who are a heterogenous group . . . are people who are very strongly against getting vaccinated . . . a substantial proportion that has had a wait-and-see attitude” (McNamara, 2021).

Liu and Li (2021) further defined the In-Betweeners as a sociocultural group that is very broad and highly complex. Factors affecting their hesitancy include mistrust in modern science, government, mainstream medicine, large corporations, and health authorities. Other factors cited included natural versus man-made risks, availability of health information through electronic sources, social networks, misinformation and misperceptions, past vaccination experiences, and an inclination toward philosophical, moral, or religious beliefs.

The In-Betweener group varies by race, ethnicity, and sex. For instance, McNamara (2021) and Liu and Li (2021) both explained that Blacks are hesitant due to concerns about the medical system as well as side effects and safety of COVID-19 vaccines. Liu and Li (2021) provided more detail using data from the most recent Household Pulse Survey (HPS) from the U.S. Census Bureau (2021), and discussed how hesitancy has dropped in the Black community from about 35% to below 20%, very similar to the level of Whites—an apparent thinning of the racial gap.

There are also gender differences within the In-Betweener group. McNamara (2021) and Liu and Li (2021) explained that women are more likely to be concerned about risks of a specific vaccine and the costs/benefits, whereas men are more likely to distrust vaccines and are not convinced about the gravity of COVID-19. The reader should recognize that it is best to venture into their community, listen to individual patient concerns, and then develop specific individualized approaches to reduce hesitancy to the COVID-19 vaccine (McNamara, 2021).

Bratu (2021) summarized from Batty et al. (2021) that the typical hesitant person includes women, younger adults, and an ethnic minority background with less education. Bratu (2021) and Troiano and Nardi (2021) concluded that common objections to vaccinations include being against vaccines, concerns about safety, the manufacturing process was too fast and not safe, skepticism about the risk of COVID-19, belief they are already immunized from prior exposure, and reservations about vaccine efficacy.

Individual and Social Determinants of COVID-19 Vaccine Uptake

There are other differences in those who are hesitant to vaccinate. Viswanath et al. (2021) conducted a survey before the vaccines were available with interesting results. For instance, those least likely to vaccinate themselves or their children received their news on conservative outlets, who had low trust in scientists, or were Republican in political beliefs, whereas those who viewed mainstream media, Google, or Yahoo news tended to be more accepting of vaccinating. Viswanath et al. (2021) found that when evaluating perceptions of risk, those who felt they were more at risk from disease or that the outcomes would be unfavorable were more likely to vaccinate. On the contrary, just because there was someone in the family with COVID-19 did not correlate with a likelihood of vaccinating. Another curious finding was that those individuals who were not working were more likely to vaccinate than those are working, with retired people and students being among the highest to be vaccinated (Viswanath et al., 2021). Others who were less likely to vaccinate themselves and their loved ones were non-Hispanic Blacks, and those less educated (Viswanath et al., 2021). The literature suggests that the increasing numbers of individuals who question vaccines and who are vaccine-hesitant have become a growing threat to public health and the reasons (questioning side effects, safety, efficacy, and the recommended vaccine schedules) may lead to unvaccinated or undervaccinated clusters around the nation where preventable COVID-19 outbreaks could occur.

Implications for Work and Occupational Health Nursing Practice

What can a nurse do to better educate patients and family members while increasing COVID-19 vaccination levels? Doheny (2021) cited from “News & Polls: News. Thanksgiving is Back on This Year” (2021) that 20% of Americans reported they are not likely to be vaccinated, whereas 14% of those are not at all likely to accept the vaccine. However, Hamza (2021) on Medpage reported that less than a third of study respondents said they would not accept the vaccine in late 2020 but became vaccinated in early 2021—leading one to conclude that many of the hesitant patients would be willing to accept vaccine with further targeted education.

There are several educational techniques for nurses to use when planning targeted interventions aimed at vaccine hesitancy or refusal (Doheny, 2021). These include (a) discussion regarding the trends of vaccine acceptance among Americans while employing an expression of compassion and concern for the patient and their loved ones and ending with a clear clinician recommendation based on guidelines; (b) allowing the patient freedom of choice while providing firsthand stories about others getting vaccinated with successful outcomes; and (c) allowing time for the patient to talk, share concerns, and ask questions, whereas the clinician employs reflective listening without judgment and provides facts regarding individualized risks of illness and the benefits of vaccination. This enables the patient to fit vaccination into their worldview to overcome vaccine hesitancy (Doheny, 2021).

Strategies for Nurses to Promote Vaccine Acceptance

Several methods nurses can use to encourage hesitant and unwilling Americans to get vaccinated are discussed by Laine et al. (2021). By increasing patient trust in the COVID-19 vaccines, nurses will help patients understand the benefits and risks of COVID-19 vaccines. Laine et al. (2020) further described a panel discussion where providers encouraged the avoidance of categorizing patients as pro-vaccine or anti-vaccine as most patients can be found somewhere in the middle of the spectrum. For many of these patients to accept vaccination it must be available, convenient, and affordable (Laine et al. 2020).

Liane et al. (2021) recommended four steps in educating patients who are vaccine-hesitant. First, misinformation must be proactively addressed by providing information that is factual and presented to the hesitant patients by nurses who are trusted and reflect the demographic characteristics of the patient population. Second, the nurse needs to acknowledge patient concerns about COVID-19 vaccine and not dismiss them. Acknowledge that there is currently a lack of information about long-term safety of COVID-19 vaccines and that the mRNA technology is still relatively new but has been under development since 1990 when Wolff et al. (1990) discussed the first successful injection of in vitro mRNA into mouse muscle to encode a desired protein within living tissue—recognizing that the science is not as new as some may believe. Liane et al. (2021) emphasized that the nurse should focus on the balance of risks versus benefits and the mRNA vaccines will not harm the genes of the patient.

Third, Liane et al. (2021) suggested nurses work to manage the expectations of the public. The goal of the COVID-19 vaccination is to promote health, keep people out of the hospital, and reduce mortality. With the approved vaccines the goal is to prevent transmission of the virus to approach herd immunity and bring the pandemic to an end. All Americans want to see the end of masking and return to the life we remember from 2019—and vaccinating more Americans will help achieve this goal.

Fourth, when discussing patient questions about vaccine effectiveness and safety, Liane et al. (2021) recommended including information about the extensive trials including members of all ages, many with comorbidities, and a variety of racial and ethnic backgrounds prior to the EUA. Nurses must establish our beliefs and display confidence that we ourselves have been vaccinated and the benefits of vaccination more than offset the risks of vaccination.

Another approach nurses can use with patients supports the points made by Thomson et al. (2018), in an editorial published in Vaccine in 2018: “Saying it is not enough: Target your communications to the needs of your audience.” This point reminds the author of a discussion with a physician when he demonstrated his approach with patients:

You are my patient. I like you and don’t want you to get sick or die. You need to be vaccinated to protect yourself and your family—as almost all my patients have done. Our team will be in shortly to administer the vaccine to keep you healthy and safe.

This conversation has been confirmed with other nurses who are familiar with this physician and his lifelong efforts to promote vaccine in all adults and assumes the patient will accept adult-targeted vaccines based upon the clinician/nursing team’s recommendation.

Guidelines and Resources

Relias Media (2021) suggested some of the following approaches when working with patients, messages that have been successful in prior flu vaccination campaigns: First, create a sense of urgency in the patient to make and keep the appointment. Second, the nurse should provide an explanation about HOW the COVID vaccines were developed, the clinical trial process, and evidence supporting their explanations. For the beginning of a nurse’s self-education, the information found on “Developing COVID-19 vaccines” (Centers for Disease Control and Prevention [CDC], 2021a) would be a great place to start. This discussion will help the worker see that the mRNA technology is not as new as many believe. During dialogue with patients, it is important for the nurse to listen to the questions of the patient silently and through a mutually respectful exchange establish a sense of trust between the patient and the nurse.

It is important that health care workers avoid perpetuating myths and misinformation about the vaccine and set an example for the community by not refusing the COVID-19 vaccine themselves (Relias Media, 2021). Common reasons for vaccine hesitancy or refusal include mistrust of government and pharmaceutical companies, concerns about side effects, widespread misinformation on social media, and concerns from Black health care workers resulting from a history of medical racism. Nurses should remember that misinformation is often spread through social media and that misinformation in the community is continually changing. It is recommended that nurses and other health professionals monitor social media and what is being discussed within the community to prevent the spread of misinformation by proactively addressing myths of misinformation identified. “When you hear something, say something” to address misinformation that does not appear factual (Berry et al., 2021).

It is strongly recommended that the nurse is prepared to provide good information about vaccines enabling the nurse to lead the discussion with a focus of providing correct information (Berry et al., 2021). In addition, as a best practice for nurses, patients should be encouraged to share this information with others within the community. Berry et al. (2021) published two tables that provide lessons learned from frontline health care workers and staff with concerns raised by the workers and examples of suggested response to these concerns (Link to Berry Tables). Reviewing these tables with the suggested responses will enable nurses to be prepared for difficult questions and concerns. Examples of these concerns include returning to prior activities after the pandemic, combating fear and anxiety, and addressing the concerns from people of color.

It is important for nurses to rely on evidence-based materials when implementing a plan to address vaccine hesitancy and refusal with their patients and co-workers. Although research indicates that many nursing staff get their vaccine information from friends or social media (Berry et al., 2021), the nurse must be prepared to continue the dialogue with patients, family, and friends so misinformation can be corrected. For this reason, there are several reliable evidence-based resources listed at the end of this article (see Nurse Resources for Talking About COVID-19 Vaccines) that nurses and other health care professionals can use to educate themselves, their patients, and their family members about misinformation to help increase the likelihood that patients and their families will accept vaccines. In addition to these resources, the CDC (2021c) recommends strategies for addressing COVID-19 misinformation that nurses can utilize. These strategies include listening to and analyzing misinformation circulating in the community; engaging with and listening to the community; sharing accurate, clear, and easy-to-find information to address common questions found in the community; and using trusted messengers to boost credibility.

Another potential solution to address vaccine hesitancy is through Motivational Interviewing (Gabarda & Butterworth, 2021). According to “Types of Therapy. Motivational Interviewing” (2021), Motivational Interviewing is a counseling method to help nurses identify a person’s need to change behavior by resolving conflicting feelings and insecurities. Among the principles of motivational interviewing are showing empathy toward clients, helping clients see that current behavior will not help them achieve desired goals, adjusting to client resistance, encouraging self-efficacy and optimism, and avoiding arguments and/or confrontation (Henderson, 2017). Motivational Interviewing has been used successfully in working with the homeless, mental, and/or substance use disorders (including smoking cessation) and weight loss and can be effective in addressing vaccine hesitancy (Substance Abuse and Mental Health Services Administration, 2018). Nurses should take some time to become familiar with the principles of motivational interviewing and practice them at every opportunity. It can help to change lives from multiple perspectives.

Why Is This Important for Nursing?

Vaccine hesitancy has been a concern as vaccines were first developed. Consider the controversy when Edward Jenner developed and administered the smallpox vaccine in the 1790s (Pennington, 2021). Immediately after the smallpox vaccine introduction skeptics arose, condemned it, and began to play on the fears and misunderstanding of the public (Pennington, 2021). Over 200 years later not much has changed. However, nurses must not permit fear and misunderstanding to impact the equitable access to care among disparate populations (Hooper et al., 2021). Disparate populations all have varying concerns for specific vaccines at different places and times. One of the great concerns voiced by Hooper et al. is that “without intervention, hesitancy may shift to complete refusal or remain as passive avoidance to seek out immunization.” Vaccine hesitancy has continued despite vaccinations being chosen as the first among Ten Great Public Health Achievements in the United States between 1900 and 1999 (CDC, 1999).

Hooper et al. discuss how vaccine acceptance varies by race and ethnicity and these populations are similarly less likely to receive pneumococcal and pneumonia, along with COVID-19 vaccines. This means aggressive efforts are needed to combat misinformation and disinformation among minority populations through organized educational efforts that are consistent and repetitive counter messaging to increase confidence of the public in all vaccines.

Another goal is development of programs to ensure unbiased access to ALL vaccines, including COVID-19 vaccines to assure all in disparate populations receive Doses 1 and 2, and the booster dose where applicable. It is additionally important that structural barriers such as cold-chain limitations, equal distribution of vaccines to underserved areas, and equal internet access to schedule appointments are addressed, and develop plans to provide transportation for those who live where public transportation is lacking.

Overcoming the impact of low vaccination rates due to vaccine hesitancy is only the first step for nurses to overcome before we can get close to the goal of universal vaccination for all adults, as noted by Szilagyi et al. (2021) when they mentioned that a key to overcoming hesitancy is to build trust in the community in the approval and developmental process of the COVID-19 vaccine. Szilagyi’s team noted that building trust is an essential step in ending the pandemic. All nurses must educate themselves so they can most effectively educate workers and families. A possible resource for the nurse in developing intervention strategies to promote COVID-19 vaccine confidence and uptake would be the COVID-19 Vaccination Field Guide (CDC, 2021b) found at https://www.cdc.gov/vaccines/covid-19/downloads/covid19-vax-field-guide-12-strategies.pdf. This guide focuses on strategies to overcome many of the common barriers found in communities along with 12 intervention strategies to improve vaccine confidence and uptake and can be used as a planning guide for nurses as they approach patients and workers to increase the immunization rates against COVID-19.

For more information in preparing nurses for worker encounters, please refer to the links included in the Nursing Resources for Talking About COVID-19 Vaccines. With preparation, nurses can help more patients accept vaccines and turn the corner in bringing the pandemic to an end.

Nurse Resources for Talking About COVID-19 Vaccines

CDC—Myths and Facts about COVID-19 Vaccines

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/facts.html

CDC—Key Things to Know About COVID-19 Vaccines

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/keythingstoknow.html

CDC—COVID-19 FAQs for Health Care Professionals

https://www.cdc.gov/vaccines/covid-19/hcp/faq.html

CDC—Answering Patients’ Questions About COVID-19 Vaccine and Vaccination

https://www.cdc.gov/vaccines/covid-19/hcp/answering-questions.html

SAMHSA. Empowering Change: Motivational Interviewing.

https://www.samhsa.gov/homelessness-programs-resources/hpr-resources/empowering change

Supplemental Material

sj-docx-1-whs-10.1177_21650799211073525 – Supplemental material for COVID-19 Vaccine Hesitancy and How to Address It

Supplemental material, sj-docx-1-whs-10.1177_21650799211073525 for COVID-19 Vaccine Hesitancy and How to Address It by Chad Rittle in Workplace Health & Safety

Footnotes

Applications to Professional Practice

Nurses must continually study the literature about all vaccines, particularly COVID-19 vaccines, and proactively engage patients and families to assess patient knowledge and address their concerns. The goal is to target the concerns of patients and family members and answer their questions about vaccine safety and effectiveness. Work to manage public expectations - vaccines are designed to prevent virus transmission, keep people out of the hospital, and reduce mortality. Once all questions have been answered, promote a sense of urgency to make and keep a vaccination appointment.

Conflict of Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Chad Rittle

Supplemental Material

Supplemental material for this article is available online.

Author Biography

Chad Rittle is associate professor, Nursing at Chatham University in Pittsburgh, PA for 10 years. He is the ANA (American Nurses Association) Liaison to the Advisory Committee on Immunization Practices for the past 7 years. He has a long history of working in public health and promoting universal vaccination for all adults.

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