Three following themes were identified.
There is a continuum of COVID-19 vaccination intentions among HACWs.
Participants reported a range of COVID-19 vaccination intentions, from enthusiastic acceptance (12 participants), accepting but reporting no choice in the vaccination decision due to professional role (3 participants), hesitant (i.e., wanting to “wait and see”, wanting to obtain further information before making a decision or having specific concerns) (3 participants) and rejecting (1 participant).
“In terms of the vaccine itself, I would say I’m very positive and very excited about it. I can’t wait to get my own! (enthusiastically accepting).”
“If it was mandatory I guess I kind of have to get it. (accepting but reporting no choice).”
“I guess it’s because I think with cases being relatively low in Australia and my risk of actually contracting the disease and I guess from just a selfish perspective, if I don’t need it and I can give it time and see how it pans out a bit once it’s pushed to the public. (hesitant, wanting to ‘wait and see’).”
“I’m not willing to get the vaccine any time soon unless I become really forced to do it. If I don’t get forced to do it, I’m not going to do it. (rejecting).”
In this paper we refer to enthusiastic acceptors of COVID-19 vaccination as “accepting”. Consistent with the definition of vaccine hesitancy [15
], we refer to participants who accepted but reported no choice due to professional role, participants who hesitated towards and one participant who rejected COVID-19 vaccination as “hesitant”.
Various perceptions influence COVID-19 vaccination acceptance among HACWs.
Participants discussed COVID-19 vaccination through a prism of different perceptions that had varying influences on vaccination acceptance (hereafter facilitators and barriers). We found six common perceptions (Table 2
) that acted as either facilitators or barriers to acceptance.
3.2.1. Perception 1: Level of Trust towards Science, Vaccine Development Process and Health Authorities
Accepting participants reported trust in science and research processes in general and, in particular, those underpinning COVID-19 vaccine development. Some expressed awe of the technology that was used to develop mRNA vaccines, describing it as a scientific breakthrough. Vaccine accepting participants were also more likely to report trusting health authorities and vaccine safety systems funded and operated by the government (for example, the Therapeutic Goods Administration (TGA) in Australia). They referred to the hard work being conducted “behind the scenes”. They trusted that the accelerated process of vaccine development did not compromise vaccine quality or safety. Many appreciated the transparency and timeliness with which they perceived the Federal and NSW State government shared COVID-19 information.
“So, I guess I just trust the scientific process. And then if the people that dedicate their lives to trying to develop and test these vaccines are giving it the go ahead, as long as there’s nothing shifty going on behind the scenes in the government, I’m all for it.”
“I have faith in things like the TGA… like some of the major scientific bodies, like the Lancet …I have a lot of trust in scientific rigour of certain journals and studies.”
Conversely, hesitant participants reported having many concerns about vaccine effectiveness and safety and questioned the speed of vaccine development. A few hesitant and/or refusing participants used language pitting themselves (“us”) against the government and pharmaceutical companies (“them”). Some in that group perceived that the information about COVID-19 and COVID-19 vaccines coming from ‘them’ had been scarce and not transparent. A few also reported misperceptions based on misinformation and conspiratorial thinking, for example, that information about serious adverse events following vaccination had been intentionally withheld.
“the medical or the pharmaceutical companies, they’re like pushing it because they make billions and billions of dollars… It’s going to be advantageous for them, if everyone gets vaccinated and the government pushes that idea.”
“I read articles that just really shook my nerves. They said they’re using aborted babies–male aborted babies that are like that are up to six months old to obtain whatever RNA they needed. It’s like gee, that is horrible. And I thought there’s no way I will come near this vaccine.”
The speed at which government information and recommendations about COVID-19 and vaccination changed was reported by some as contributing to a sense of uncertainty and mistrust towards official information. One participant said he “lost trust in a lot of information”
“Because there is no consistency, it is like, you wonder, how true is this information?”
3.2.2. Perception 2: Level of Confidence in COVID-19 Vaccination
Most participants reported confidence in vaccination in general and used examples of how vaccinations have helped eradicate vaccine preventable diseases. Most participants also described positive experiences with routine vaccination and would regularly vaccinate against influenza.
“I’m for vaccinations and I think for general public health measures, vaccinations seem to be proven to be a good and effective strategy for many different illnesses.”
A small number of accepting participants also highlighted the effectiveness of COVID-19 vaccines in reducing hospitalisation.
“… the AstraZeneca vaccination looks like… it decreases hospitalisation by almost 100%. So in terms of the public health measure to prevent hospital load of COVID patients, that’s obviously going to be extremely effective.”
Hesitant participants, on the other hand, reported low levels of confidence in COVID-19 vaccination and reported many concerns, discussed below under ‘Risk/benefit calculation’.
3.2.3. Perception 3: A Sense of Obligation to the Broader Community to Vaccinate
Accepting participants were more likely to describe wanting to vaccinate to protect others at work (patients and co-workers), at home (family and housemates) and in the community (friends and vulnerable community members). One person put a moral value on vaccination, perceiving vaccination as “doing your bit” and being “a good citizen”.
“Anything that I can do to help the greater community, especially in, you know, going to lots of people who are susceptible to getting diseases, I think…-it’s not much work for me, and it will do- it will help them in the long run yeah.”
“To protect myself, my friends, family, and workmates and people that I work with, clients, patients, and to play–play my part.”
This sense of obligation to the broader community to vaccinate was not reported by hesitant participants. In fact, some in that group questioned the need for the “young and healthy” (including themselves) to vaccinate at all. A few also reported confusion with the concept of herd immunity. This indicates that lack of knowledge is potentially contributing to some HACWs’ poor sense of community values of vaccination.
“Well, I just hear them thrown around on the news, like if we have herd immunity does that mean everyone is vaccinated? Like immunity, it’s just the weak, the more vulnerable, the weaker ought to be vaccinated, sure, that would be great. But for a healthy person, you know, no medical history issues, I don’t believe we should force them.”
3.2.4. Perception 4: Perception of COVID-19 Disease Risk
Accepting participants were more likely to describe the COVID-19 pandemic as serious, with global reach and to stress the negative impacts it has had on people’s lives.
They also reported high work-related risk of exposure to COVID-19. This was most pronounced for those HACWs who had experienced COVID-19 first hand at work, for example, by conducting COVID-19 testing or seeing patients with COVID-19 disease. Many reported worrying about inadvertently passing on the virus (at work, at home and in the community) and the devastating consequences (serious disease and death) this could have on those that are most vulnerable.
“… we went into a couple of nursing homes and I had a patient who was over the age of 90 and just thinking like if I was the one to give that person COVID and they were to pass away like that would just, I don’t know, that breaks my heart.”
“Yes, there needs to be more research. I get that. But if I gave COVID to someone and I killed them, essentially, or I passed it onto them and they died, I wouldn’t forgive myself.”
While most HACWs did not feel at risk of serious disease (due to being young and healthy), a few participants reported a sense of heightened personal risk due to the underlying health conditions in themselves or in immediate family members.
“I feel a sense of mild anxiety about getting COVID. No one really knows what the outcome of someone who is young, physically healthy, but immunosuppressed, would be. So I do think on these things a lot more.”
Conversely, hesitant participants were more likely to report that the pandemic risk in Australia was overstated or politicised. Some proposed that COVID-19 may be similar in severity to seasonal influenza. This was particularly the case for those who reported not knowing anyone who has been infected with COVID-19. On the premise of “not having COVID in the community at the moment”, they questioned the rush to vaccinate.
“It’s not a deadly virus. It’s not a poison.”
“We’ve had how many cases and they’re just cases, and they have to obviously self-isolate and so they’re kind of-if this COVID is just a new flu, like I don’t know.”
3.2.5. Perception 5: Risk/Benefit Calculation
Accepting participants were more likely to perceive that, while COVID-19 vaccines come with some risks, the benefits of vaccinating greatly outweighed those risks.
“It hasn’t been trialled for years and years…but what we do know is the short term and some of the concerns regarding longer-term effects of not getting the vaccine.”
Some saw COVID-19 vaccination as “necessary” and “the best chance” given that there was no cure or a single solution to the COVID-19 pandemic.
“I would get the COVID-19 vaccine because I guess as a public health measure, it seems to be the best chance we have currently to turning cases around and improving general public health outcomes for everyone globally.”
Some used combat metaphors to describe their perceptions of COVID-19 vaccination, such as referring to COVID-19 vaccination as a “weapon” in “a war on this illness”.
A large number of accepting participants discussed vaccination as a means of returning to “normality”, including unrestricted social interactions, events, domestic and international travel and entertainment.
“We need normality back. We need to be able to walk around with no masks on, be able to hug people again, be able to go and visit our grandparents in nursing homes. Life needs to be normal again. It’s too much. We need to be able to travel again. We need to be able to have fun again. And I think that’s what the vaccine–the vaccine will bring normality.”
Other reported benefits of COVID-19 vaccination included the following: protection against infection with the virus and against developing serious illness and an associated sense of personal safety; the ability to continue to work and prevent economic impacts; protection for family members living overseas; and an associated sense of relief that they would be safe once vaccinated.
“I think, just from a risk benefit perspective, I think it’s got a low level of risk and the potential of benefit is that if there was another major outbreak, that I’d feel more protected against it, not only from stopping me getting sick but stopping me from getting… COVID, being asymptomatic and giving it to patients. So, I feel like it’s an extra safety measure on top of PPE.”
“I will definitely be getting vaccine- I will feel safer, so that I don’t catch it. And less afraid of going out.”
Conversely, hesitant participants were less likely to describe the benefits of COVID-19 vaccines and more likely to voice concerns. Concerns (summarised in Table 3
) could be organised into those about COVID-19 vaccine safety and effectiveness and those about the logistics of the vaccine rollout (i.e., when and where it will be available).
“COVID’s so new, it’s from last year or the year before and then they’re making this really quickly and then they’re releasing it. What are the long-term side effects is definitely a concern and…a lot of people ask me that as well.”
“… we don’t have specific freezers, monitoring of freezers. So for me I feel like there could be some errors or mistakes made or the cold chain broken. So that for me is a little bit of concern.”
3.2.6. Perception 6: Perception of Personal Agency
Accepting participants reported feeling that they had a choice to vaccinate or not. They referred to making that choice to proactively take care of themselves and others. In that sense, COVID-19 vaccination was observed as a means to exercise personal agency around personal and public health.
“I am protecting myself and I am protecting the people that I look after and my co-workers. I am protecting my partner against it, the family.”
Conversely, hesitant participants discussed COVID-19 vaccination through a lens of limited choice and control. They used expressions such as “we are being dictated to” and “we are being told to accept it as it is”. One person stated that, while the vaccines were not explicitly mandatory, people who object would essentially be barred from having a “normal life” of travelling, working in a clinical capacity or being eligible for government support. Another person expressed fear and anger that he and other young and healthy people will be used against their will “for testing” of COVID-19 vaccines.
“They do say oh, it’s not going to be forced, but if you don’t have the vaccine you’re not allowed to do any overseas travel … -so you’re a prisoner if you don’t.”
“I don’t want to be the first person to put my hand up and say here, you can use me for tests basically.”
Information sources, people and norms influence HACWs perceptions of COVID-19 vaccines.
The participants discussed used and relied on various sources of COVID-19 vaccination information. Some accepting participants reported knowledge gained from their clinical training and/or professional experiences (i.e., being a vaccination provider and planning to be COVID-19 vaccination provider) as helpful in understanding various immunisation concepts (herd immunity; transmission of the virus to vulnerable people) and processes of vaccine development. They referred to this information, as well as that from health authorities (such as the NSW Health website), as “reliable”. This knowledge helped instill confidence in the vaccines, for example, that vaccine safety had not been compromised despite accelerated processes. Participants who reported knowledge gained from medical training and/or professional experience were more likely to critique mainstream and social media as an “unreliable” source of information.
“I am getting most of my information from the Health website, and things like journals and that kind of thing. I think that comes from the health background and not Googling it.”
“I try and get my news and articles from reputable sources not tabloid news journalism… Something that’s evidence-based or backed by research, not so that they’re just opinion pieces.”
Participants also reported accessing mainstream and social media, but some hesitant participants reported confusion with the COVID-19 vaccination content presented there. This content included the changing information and advice on the COVID-19 pandemic and misinformation about COVID-19 vaccination.
“You can go online and a video will come up on your Facebook or your Instagram and it will be some lady having seizures and stuff, post-vaccination. But then you don’t know whether to believe that was actually the case of the seizures and whatnot.”