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IJERPHInternational Journal of Environmental Research and Public Health
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5 November 2026

14 Pages

Social and Political Differences in COVID-19 Vaccination and Vaccine Readiness Among RN-to-BSN Nursing Students

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and
1
Department of Public Health & Health Sciences, College of Health Sciences, University of Michigan-Flint, Flint, MI 48502, USA
2
Office of Access and Equal Opportunity, Norfolk State University, Norfolk, VA 23504, USA
3
Department of Public Health, Michigan Public Health Institute, Okemos, MI 48864, USA
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health2026, 23(11), 1393;https://doi.org/10.3390/ijerph23111393 
(registering DOI)
This article belongs to the Collection COVID-19 Research
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Highlights

Public health relevance—How does this work relate to a public health issue?
  • Vaccine hesitancy, or the delay or refusal to obtain safe vaccines despite their availability, threatens the lives of individuals, communities, and our global society.
  • Vaccine hesitancy among nurses is a significant public health issue that can undermine trust and vaccine uptake in the public.
Public health significance—Why is this work of significance to public health?
  • Although RN-to-BSN nursing students are trained in a science-based discipline, they may benefit from media literacy training that enhances critical-thinking and one’s ability to identify vaccine misinformation and disinformation.
  • Understanding and addressing COVID-19 and other vaccine misinformation and disinformation among nurses is critical to keeping a safe, informed, credible and trustworthy workforce.
Public health implications—What are the key implications or messages for practitioners, policy makers and/or researchers in public health?
  • While socio-demographic factors such as race/ethnicity remain important determinants of vaccine hesitancy, research suggests political factors may also play an influential role in vaccine hesitancy among healthcare professionals and the general public.
  • Research suggests that political affiliation can influence vaccine hesitancy. Thus, researchers should study it and its mechanisms alongside traditional socio-demographic factors to better understand and address challenges to vaccine uptake among healthcare professionals and the general public.

Abstract

Background: Research demonstrates a strong relationship between healthcare professionals’ vaccine attitudes and behaviors and the vaccination behaviors of patients, family, and friends. Positive vaccine attitudes among healthcare professionals are associated with vaccine uptake among patients and non-patients. Relatedly, vaccine hesitancy among healthcare professionals is associated with decreases in vaccine uptake. Understanding and addressing vaccine hesitancy among healthcare professionals, such as nurses, is a critical public health issue. Purpose: This study examines social and political differences between COVID-19 fully vaccinated (FV) and not fully vaccinated (NFV) nursing students. Methods: An online survey was distributed to investigate the social (i.e., age, gender, race/ethnicity, and religious affiliation) and political (political affiliation) differences in COVID-19 vaccination among RN-to-BSN nursing students. Among the NFV, readiness for COVID-19 vaccination and reasons for vaccine hesitancy were also assessed. The final analytic sample included 192 respondents. Descriptive and bivariate analyses were conducted to identify whether socio-demographic and political differences existed between COVID-19 FV and NFV nursing students. Results: Political affiliation (p = 0.005) was the only statistically significant difference identified. Among the NFV, the majority (70.8%) were in the precontemplation stage, with no intention of becoming vaccinated in the foreseeable future. The top reason reported for vaccine hesitancy was concern about side effects (58.3%). Implications: Political affiliation is an important factor in understanding vaccine hesitancy. Strategies to build trust, engage in empathetic discussions about vaccine hesitancy, and enhance media literacy skills are crucial steps in addressing vaccine hesitancy and the influence of politics on public health issues.

1. Introduction

Healthcare workers are essential to our health systems and keeping our communities safe. Healthcare workers, such as doctors and nurses, influence vaccine attitudes, beliefs, and the behaviors of their families, friends, and patients by role-modeling preventive behaviors and providing necessary education and encouragement. When healthcare workers express vaccine hesitancy and/or actively refuse to get vaccinated, they can undermine the public’s trust in these important preventative health behaviors [1,2,3]. Due to the critical role healthcare workers play in vaccine promotion and education, it is imperative that we understand and address factors that contribute to their vaccine hesitancy. Thus, the primary purpose of this work is to determine whether socio-demographic differences exist among healthcare professionals who have completed their COVID-19 vaccinations and those who have not. Specifically, we will explore whether differences exist by age, gender, race/ethnicity, and religious and political affiliations. Secondly, among the NFV group, we explore vaccine readiness and reasons for not completing their COVID-19 vaccine(s). This information will provide important insights for addressing COVID-19 vaccine hesitancy, and vaccine hesitancy more broadly, among U.S. health professionals and the general public.

2. Literature Review

2.1. Age & Vaccine Hesitancy

Vaccine hesitancy is defined by the World Health Organization [4] as the delay or refusal to receive a vaccination when it is available. Studies on vaccine attitudes and behaviors, including vaccine hesitancy, reveal fairly consistent patterns across various vaccine types and populations. In general, older adults (65+) are more likely to engage in vaccine uptake, whereas younger adults are more likely to be vaccine-hesitant [5,6,7]. For example, Gravelle et al. [8] examined general vaccine attitudes and attitudes toward COVID-19 among samples drawn from the U.S., the U.K., and Canada. Data drawn from this cross-sectional study were used to develop four classes of attitudes towards vaccines: strong supporters, supporters with concerns, vaccine hesitants, and anti-vaccinators. Findings revealed that vaccine hesitancy in the United States was most prevalent among those aged 25–49 (30.3%) and least prevalent among those 65 and older (13.1%). These findings are consistent with other research, such as Sieber et al. [7], who examined hesitancy towards COVID-19 vaccination among (n = 10,313) Southern California residents. In this work, those aged 18–29 had 2.16 times greater odds of being vaccine hesitant (before adjusting for confounders) and 1.46 times greater odds (after adjusting) compared to those aged 70+. Finally, a study conducted by Lee et al. [6] examined COVID-19 vaccination among U.S. healthcare professionals with and without COVID-19 vaccine requirements. Similar to findings concerning the general U.S. population, COVID-19 vaccination was lowest among the youngest group of healthcare professionals (18–29) for both agencies with and without COVID-19 vaccine requirements. As evidenced by these studies, the association between younger age and greater vaccine hesitancy persists across vaccine type and population (the general US population and US healthcare professionals).

2.2. Gender & Vaccine Hesitancy

It is well-documented that women utilize healthcare services more frequently than men [9]. Despite this, a growing body of literature suggests that women are more vaccine-hesitant than men [10,11]. Using data from the 2021 US Household Pulse Survey (n = 50,359), Morales et al. [12] found that women were more concerned about COVID-19 vaccine side effects and were more vaccine-hesitant than men. These findings are consistent with other studies [7,13,14,15], that identify greater COVID-19 vaccine hesitancy among women than men. Studies on COVID-19 and healthcare workers also find that women are more vaccine-hesitant than men [16,17].

2.3. Race/Ethnicity and Vaccine Hesitancy

When it comes to vaccine hesitancy, ethnic minority populations such as African Americans and Hispanics report higher levels of vaccine hesitancy than their non-Hispanic White counterparts [8,18]. According to Webb Hooper et al. [19], racial/ethnic minority populations are less likely to receive routine vaccines such as influenza and pneumococcal vaccinations. When it comes to COVID-19 vaccination, several studies have identified an association between COVID-19 vaccine hesitancy and Black/African American race/ethnicity [7,15,20,21]. According to Litaker et al. [14], COVID-19 vaccine hesitancy among African Americans is linked to concerns about the vaccine development timeline, a lack of data on vaccine side effects, and mistrust of the medical establishment. Among healthcare professionals, those of African American race/ethnicity continue to report higher rates of vaccine hesitancy compared to their white counterparts [21], with the exception of African American physicians [22].

2.4. Religion and Vaccine Hesitancy

The influence of religion on vaccine hesitancy has not been studied consistently. While some scholars have studied religious identity [23,24], others have studied the relationship between religious beliefs and vaccine hesitancy [25,26]. Regardless of how religion has been operationalized within vaccine research, religion remains a significant contributing factor to vaccine hesitancy [27]. For example, Olivera-Figueroa et al. [28] found that religious beliefs were negatively associated with intention to vaccinate against COVID-19. In particular, Levin and Bradshaw [29], as well as others [23,30], found that conservative religious beliefs were strongly associated with COVID-19 vaccine hesitancy. Among healthcare professionals, the influence of religion on vaccine hesitancy is an understudied area of research. Only one study was identified that examined this relationship, focusing on the responses of (n = 8243) nursing home and senior living staff in Indiana. This study, conducted by Unroe et al. [31], found that 12% listed religion as a reason for their vaccine hesitancy.

2.5. Political Affiliation and Vaccine Hesitancy

Just as religion can shape one’s values, attitudes, and behaviors, including attitudes and behaviors about vaccination, so too can political ideologies [32,33]. In the United States, partisan differences in communication about the cause of the COVID-19 pandemic, its severity as a public health threat, and the effectiveness of preventive behaviors such as masking, social distancing, and vaccination are well-documented [33,34]. These differences, when coupled with overarching ideological differences about the role of government—where conservatives champion limited government (vs larger government) and consider its expansion a threat to individual freedom [3,35,36], have played an important role in shaping COVID-19 vaccination. Several studies report higher vaccine hesitancy among conservatives and Republicans compared to Democrats [8,29,34,36,37], while another study found that differences between Republicans and Democrats narrowed over time, but, that vaccine hesitancy remained high among Independents [38]. Still, other studies have observed a complex interplay between religious and political factors, noting that Christian Nationalism was a stronger predictor of COVID-19 vaccine hesitancy than conservative religiosity alone [30,39]. While few studies have examined the relationship between political affiliation and COVID-19 vaccine hesitancy among healthcare workers, evidence suggests patterns similar to those observed among the general public. Specifically, Republicans and those with conservative leanings are found to have higher levels of vaccine hesitancy than Democrats [36]. Research by Peterson et al. [3] also found that COVID-19 vaccine hesitancy was negatively influenced by conservative political ideologies, in which vaccine mandates were perceived as an infringement on personal rights.

2.6. Vaccine Intentions

At the time this research was conducted, our university required all students to be vaccinated unless they had a medical or religious exemption or were enrolled in a fully online degree program. The vast majority of healthcare systems within the state of Michigan also implemented COVID-19 vaccine mandates. Yet, some healthcare professionals remained not fully vaccinated. To better understand vaccine attitudes and beliefs among not fully vaccinated healthcare workers, we examined vaccine intentions and reasons for not receiving the COVID-19 vaccine among our sample of NFV nursing students. Research has shown that health-related behavioral intentions are causally linked to health behaviors [5,40].
We utilize the Transtheoretical Model (TTM) to understand COVID-19 vaccine readiness and intentions. The TTM is a model used to understand processes involved with the adoption of healthy behaviors or lifestyle changes, such as smoking cessation. The stages of change include: precontemplation, contemplation, preparation, action, maintenance, and termination. In the precontemplation stage, individuals have no intention of acting in the foreseeable future, typically defined as within the next six months. The contemplation stage is when individuals intend to change in the next 6 months. Preparation is defined as when individuals intend to adopt a new behavior within the immediate future, typically within the next month. The action stage is characterized by individuals making specific, overt lifestyle modifications within the past six months. The maintenance stage is characterized by individuals actively working to prevent relapse into old behaviors. Finally, the termination stage is reached when individuals have zero temptation and 100% self-efficacy (i.e., personal belief in one’s own abilities) to maintain their behavior change [41]. Depending upon one’s readiness for health behavior change, different strategies can be employed to encourage progression towards the next stage and ultimate adoption of the recommended health behavior. In addition to studying vaccine readiness via the TTM, we also investigated common reasons for not completing one’s COVID-19 vaccine(s), including concerns about vaccine efficacy and side effects [1,3].

3. Methods

3.1. Study Design

This cross-sectional study investigated socio-demographic differences in COVID-19 vaccination using an online survey distributed to nursing students enrolled in the Registered Nurse (RN) to Bachelor of Science in Nursing (BSN) program at a Midwestern public university. The majority of our sample (85.1%, data not presented in the tables) were employed as nurses at the time the study was conducted. We assessed employment status by asking respondents whether they were currently employed as a registered nurse (yes/no). Data were collected between 13 December 2021, and 28 January 2022. The online survey was administered via Qualtrics. This 35-item survey measured demographic characteristics of FV and NFV nursing students, including age, gender, race/ethnicity, as well as political and religious affiliations. Vaccine readiness and primary reasons for COVID-19 vaccine hesitancy were also assessed. This study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies [42], the completed STROBE checklist is provided as Supplementary Material File S1.

3.2. Subjects & Protections

Nursing faculty recruited nursing students through classroom announcements and email. Study eligibility included students currently enrolled in the RN-to-BSN program at a single public university in the Midwest and excluded all other students. A total of 230 surveys were received. Of these, 34 were incomplete, defined as missing >50% of data, and an additional 4 were removed because of missing vaccine status data, resulting in a final analytic sample of 192 participants.
When accessing the study survey, participants were required to sign an electronic informed consent statement before proceeding. Failure to sign the informed consent resulted in the student being redirected from the survey to a “thank you for your interest” message.
All participant data were collected anonymously; however, participants could enter their email address into a drawing to win one of three $50 Visa gift cards for completing the survey. Only non-nursing research team members were involved in selecting and distributing drawing winners. This study was reviewed and approved by the university’s Institutional Review Board (HUUM00206885).

3.3. Measures

Socio-demographic variables measured in this study included age, gender, primary race/ethnicity, religious affiliation, and political affiliation. Age was measured by asking respondents, “What is your age?” Responses were self-reported. Gender was measured by asking respondents, “What is your gender?” Response options included male, female, transgender, other, and prefer not to say. Primary race/ethnicity was measured by asking respondents, “What is the primary race/ethnicity in which you identify?” Self-reported response options included American Indian/Alaskan Native, Arab/Middle Eastern, Asian, Black/African American, Hispanic/Latinx, Hawaiian or Pacific Islander, White/Caucasian, Other, and Care not to respond.
Religious affiliation was measured using a modified version of Baker and Smith’s [43] item, “What religious family do you belong to or identify yourself most close to?” Response options included Christian, Protestant Christian, Non-Denominational Christian, Catholic, Mormon, Jehovah’s Witness, Jewish, Muslim, Buddhist, Hindu, Atheist, Other, and Care not to respond. Finally, political affiliation was measured by asking respondents, “What is your political affiliation, if any?” Response options included Republican/Conservative-leaning, Democrat/Liberal-leaning, Independent, Other, None, and Care not to respond.
COVID-19 vaccine status was measured by asking respondents, “Are you fully vaccinated against COVID-19? (Received two shots of Moderna or Pfizer or a single shot of Johnson & Johnson).” Response options included “yes” and “no.” For respondents who answered “no” to being fully vaccinated against COVID-19, two follow-up questions were asked to assess vaccine readiness and reasons for vaccine hesitancy.
The research team developed a measure of vaccine readiness based on the Transtheoretical Model (TTM), also known as the Stages of Change. Respondents were asked to complete this statement: “When it comes to COVID-19 vaccination…” Response options included, “I have no intentions of getting vaccinated in the foreseeable future, i.e., in the next six months,” “I intend to get vaccinated within the next 1–6 months,” “I intend to get vaccinated within the next 30 days,” “I have already set an appointment to get vaccinated,” and “I have already started my vaccine series but have not completed it yet.”
Similarly, our research team constructed a multi-response measure of vaccine hesitancy, drawing from existing literature and professional experience. Respondents were asked to select all the answers that apply to the prompt “Reasons I have not been vaccinated.” Response options included, “Immunocompromised and unable to receive the vaccine,” “I was diagnosed with COVID-19 and have protective antibodies to fight the virus without needing to be vaccinated,” “I do not believe that COVID-19 is a life-threatening disease for healthy people such as myself,” “COVID-19 vaccines are unsafe,” “I am concerned about the speed in which the vaccine was developed,” “I am concerned that some COVID-19 vaccines have only been authorized for emergency use and have not received full FDA approval,” “I am concerned about adverse side effects,” “COVID-19 vaccines are ineffective and have suboptimal protective efficacy,” “I disagree with vaccinations,” “I believe the push for vaccines is political and not about health,” “Fear of injections” and “Other.” “Other responses” included a text box for respondents to provide a written response.

3.4. Analytic Plan

Using IBM SPSS Statistics software version 32, descriptive statistics were conducted and analyzed to identify social (i.e., age, gender, race/ethnicity, and religious affiliation) and political (political affiliation) factors associated with COVID-19 vaccination among nursing students. Independent-samples t-test, Fisher’s exact test, and Pearson’s chi-square test were conducted when appropriate to determine statistically significant differences between groups (i.e., FV and NFV).

4. Results

Table 1 examines the socio-demographic characteristics of the study sample by COVID-19 vaccine status. For age, FV respondents had an older mean age (35 vs. 32 years) than NFV respondents, though these differences were not statistically significant. Due to the very small number of respondents answering “other” or “prefer not to respond” to our gender question, we removed these cases from our analyses and compared the distribution of men and women by vaccine status. Women comprised the largest proportion of both FV and NFV groups (86.1% and 95.8%, respectively), while men made up much smaller proportions of each group (13.9% and 4.2%, respectively). No statistically significant differences were detected for gender between the FV and NFV groups. Regarding one’s self-identified primary race/ethnicity, Whites were the largest racial/ethnic group among both FV and NFV respondents (83.9% and 62.5%, respectively). However, a higher percentage of American Indian/Alaskan Native, Arab/Middle Eastern, Black/African American, and Hispanic/Latinx respondents were in the NFV group. To test whether a statistically significant difference existed between FV and NFV respondents regarding race/ethnicity, categories were collapsed to compare whites and non-whites. We collapsed categories to account for small sample sizes within our non-white categories. Results were not statistically significant (p = 0.073).
Table 1. Socio-demographic characteristics of study sample by COVID-19 vaccine status.
Next, we examined respondents’ religious affiliation. Christians (any) were the larger group for both FV (55.1%) and NFV (62.5%) respondents, though the FV group showed greater religious diversity, with a higher proportion of respondents identifying most closely with Jewish, Buddhist, Hindu, Atheist, and “other” religious groups (31.2% and 16.6%, respectively). To test whether a statistically significant difference existed between FV and NFV respondents, religious categories were collapsed to compare Christians (of any denomination), non-Christians, and Other/Refused. We collapsed categories to account for small sample sizes within our non-Christian categories. We did not detect a statistically significant difference (p = 0.30) in religious affiliation by vaccine status. Finally, we examined respondents’ political affiliation.
A greater proportion of respondents in the FV group identified as Republican/conservative-leaning, Democrat/liberal-leaning, independent, and other, compared to the NFV group. In contrast, a greater proportion of respondents in the NFV group identified as having no political affiliation or refused to respond. To determine whether a statistically significant difference existed between FV and NFV respondents regarding political affiliation, our categories were collapsed into the following groups: Republican/conservative-leaning, Democrat/liberal-leaning, Independent/other/none, and refused. We collapsed categories to account for small sample sizes within our independent, other, and no political affiliation categories. Fisher’s Exact test revealed a statistically significant difference (p = 0.005) in the distribution of self-reported political affiliation by vaccine status.
Table 2 summarizes responses regarding COVID-19 vaccine readiness among NFV nursing students. The largest percentage of NFV respondents (70.8%) reported being in the precontemplation stage, with no intention of becoming vaccinated in the foreseeable future (i.e., within the next 6 months). The second most common stage among NFV respondents (12.5%) was the contemplation stage, in which respondents intended to receive their COVID-19 vaccines within the next 1–6 months. An equal percentage of respondents (8.3%) were in the preparation and action stages. Those in the preparation stage were defined as those who had already taken their first steps towards vaccination, including those who intended to get vaccinated within the next month (preparation A) and those who scheduled an appointment but had not yet received their vaccine(s) (preparation B). Those in the action stage included respondents who had already started their vaccine series but had not completed it.
Table 2. COVID-19 vaccine readiness.
Table 3 highlights the distribution of NFV nursing students’ responses to common reasons for not completing their COVID-19 vaccine(s). The most common response was concern about side effects (58.3%). Being diagnosed with COVID-19 and having protective antibodies and concern about the speed of vaccine development were the second most common responses, with 45.8% of NFV affirming these responses. The third most common reasons (29.2%) reported for not completing COVID-19 vaccination were tied between concerns that vaccines were only authorized for emergency use and did not receive full FDA approval, the belief that COVID-19 vaccines are ineffective and have suboptimal protective efficacy, and the belief that politics, rather than health concerns, drove the push for vaccination. The fourth most common reason (16.7%) reported for not completing their COVID-19 vaccination(s) was the belief that the push for vaccines is driven by profit rather than health. The fifth most common reason (12.5%) reported for not completing their COVID-19 vaccination(s) was tied between the belief that COVID-19 is not life-threatening and the concern that COVID-19 vaccines are unsafe. The sixth and least common reason (4.2%) was also tied between people who reported being immunocompromised and those who stated they disagreed with vaccines. No one reported not receiving a COVID-19 vaccine due to a fear of injections.
Table 3. Reasons for not completing COVID-19 vaccination(s) 1.

5. Discussion

This research examines the social and political profiles of RN-to-BSN nursing students who have completed their COVID-19 vaccine(s) and those who have not. Despite well-documented relationships between socio-demographic factors, such as age, gender, race/ethnicity, religion, and vaccine hesitancy [7], we did not find statistically significant differences between our FV and NFV groups. The only statistically significant difference was political affiliation (p = 0.005). Nearly 63% of NFV respondents reported no political affiliation (33.3%) or “refused to respond” (29.2%) compared to 22% of the FV group (14.9% and 7.1%, respectively). These findings underscore the importance of examining socio-demographic factors alongside political factors in studies of vaccine hesitancy for healthcare professionals.
Among the NFV group, we also examined vaccine readiness and reasons for vaccine hesitancy. The vast majority (83.3%) of NFV respondents were in the earliest stages of change, namely precontemplation (70.8%) and contemplation (12.5%). The top three reasons for vaccine hesitancy included (1) concern about side effects; (2a) being diagnosed with COVID-19 and having protective antibodies; (2b) speed of vaccine development; (3a) the vaccine only being authorized for emergency use; (3b) the belief that COVID-19 vaccines are ineffective and have suboptimal protective efficacy; and (3c) the belief that politics were driving the push for vaccines.
Our observation that vaccine hesitancy differed in the distribution of political affiliation is consistent with a growing body of literature that suggests that political affiliation and ideologies can influence vaccination attitudes and behaviors of healthcare professionals [3,36]. These results contribute to vaccine promotion research by highlighting the relationship between political affiliation and vaccine attitudes and behaviors among nursing students. While the relationship between political affiliation and vaccination has been studied on a larger scale among the general U.S. population, very few studies have examined the role of politics in healthcare professionals’ vaccine behaviors. Our study thus provides new evidence supporting the finding that political affiliation may be an important factor in understanding vaccine attitudes and behaviors among healthcare professionals such as RN-to-BSN nursing students, warranting greater attention in vaccination education and promotion efforts for both healthcare professionals and the general public.
There may be several mechanisms at play in understanding how politics and political ideologies influence healthcare professionals’ vaccine attitudes and behaviors. One of the more prominent explanations concerns the relationship between political affiliation and information seeking. Several studies have reported a correlation between information-seeking behaviors, such as the use of social and conservative media, misinformation, and vaccine hesitancy [44,45]. While examining the information-seeking behaviors of healthcare professionals is beyond the scope of this work, it is crucial for those working in vaccine education and promotion to understand the mechanisms by which political affiliation influences vaccine attitudes and behaviors. Be it information overload, misinformation, belief in conspiracy theories, or an inability to formulate an accurate health risk assessment for oneself, understanding how political affiliation shapes vaccine attitudes and behaviors will provide critical insight for identifying key points and strategies for intervention [44,45].
The role of politics and misinformation in vaccine decision-making remains relevant in the post-pandemic period, particularly as public health recommendations and vaccine policies continue to evolve. Recent changes to U.S. childhood immunization guidance, including updates to measles, mumps, and rubella (MMR) and measles, mumps, rubella, and varicella (MMRV) vaccination recommendations, have occurred alongside increasing political polarization around vaccination. Although MMR vaccination continues to be recommended for children, changes in the broader childhood immunization schedule and conflicting public messages may create confusion and contribute to uncertainty about vaccination. Recent research further suggests that misinformation circulating through social media and other information sources is associated with MMR vaccine hesitancy, while political polarization has increasingly extended to childhood vaccination decisions [46,47,48,49,50].

Vaccine Readiness and Reasons for Vaccine Hesitancy

At the time that this study was conducted, the university under study required all students to be vaccinated against COVID-19. Only fully remote students and students with medical or religious exemptions were able to receive vaccine waivers. Likewise, the majority of hospitals and clinics in the state required healthcare workers to be vaccinated or face possible termination [50]. Given this context, it is not surprising that the majority of our sample was FV and that those who were NFV had no intention of being vaccinated in the near future (next six months).
The attitudes, values, and beliefs of NFV nursing students are likely well-established and deeply ingrained. Indeed, they may be fundamental to the individual’s worldview. Addressing these attitudes, values, and beliefs therefore requires the utmost care and empathy. Public health professionals must work to build trust with all individuals, regardless of occupation, education, or other socio-demographic and political factors.
Those in the precontemplation stage (no intention of changing their behavior in the next six months) are often characterized as lacking information. Theoretical examples of this stage may include having limited knowledge or understanding about the recommended behavior (COVID-19 vaccination) and/or lacking awareness of how their behavioral choice (not getting vaccinated) can impact themselves or others. Likewise, these individuals may deny the existence or downplay the significance of the health problem (COVID-19). They may be defensive when confronted about their behavior. Tailored interventions that focus on promoting the benefits of COVID-19 vaccination, while debunking myths and correcting misinformation, are effective strategies for addressing vaccine hesitancy [51,52,53]. But other strategies, such as looking for common values and improving media literacy, may be more effective [50]. For example, a longitudinal study examining social media use and COVID-19 in the U.S. found that while consuming social media content related to COVID-19 promoted vaccine hesitancy via skepticism in vaccine effectiveness, this relationship was moderated by media literacy such that those with lower literacy were more likely to be vaccine hesitant [54]. Subsequently, these authors suggested that improving media literacy could buffer the negative effects of social media on vaccine attitudes and beliefs. Developing skills to critically evaluate sources of information such as their scientific credibility and potential motives, fact-checking, and understanding the difference between causation and correlation, can all enhance media literacy. Future vaccine education and communications efforts should focus on these practical, critical-thinking elements.

6. Conclusions

While our study makes several contributions to the extant literature on vaccine hesitancy among healthcare professionals, important limitations exist. First, our sample of NFV nursing students was very small, which limited the types of analyses we could conduct. Additionally, we could not determine the number of eligible RN-to-BSN students to calculate a non-response rate. Respondents in our sample may differ from non-respondents. Likewise, our use of primary race/ethnicity did not allow us to examine vaccine hesitancy among multi-racial respondents.
Second, while we drew heavily from existing literature on the relationship between political affiliation and vaccine hesitancy, the majority of NFV respondents in our study did not identify as politically conservative but, rather, “other” or “refused to respond”. As such, we cannot be sure the same mechanisms influencing vaccine attitudes, beliefs, and behaviors are at play. Additional research, particularly qualitative research, may help us better understand how various political identities shape vaccine attitudes, beliefs, and behaviors.
Finally, our study is based on the experiences of RN-to-BSN nursing students, the majority of whom were employed as nurses at the time of the study. Healthcare professionals include a wide range of professions with different levels of scientific training and experience. As such, we must be careful not to overstate or extrapolate the current findings beyond the study sample. Rather, this work should inform future research on the role of social and political factors on vaccine hesitancy among U.S. healthcare professionals and the public more generally.
As previously stated, our research makes several contributions to the literature on vaccine hesitancy. In recognizing the critical role healthcare professionals such as nurses play in shaping others’ vaccine attitudes, beliefs, and behaviors, we focus on understanding barriers to vaccine uptake among these key health information providers. Second, we importantly expand the currently limited number of studies that investigate the role of political affiliation on vaccine hesitancy among healthcare professionals. Third, our work employs health theory to understand vaccine hesitancy within a stage of change framework to identify appropriate strategies to counter vaccine hesitancy and promote vaccine uptake. Fourth, this work provides practical advice for addressing vaccine hesitancy among healthcare professionals by advocating for tailored efforts that empathetically work to find common values, address inaccurate health information and risk perceptions, and enhance media literacy.

Supplementary Materials

The following supporting information can be downloaded at https://www.mdpi.com/article/10.3390/ijerph23111393/s1: File S1: STROBE Statement—checklist of items that should be included in reports of observational studies.

Author Contributions

Conceptualization, L.M.L., B.C. and J.J.; Methodology L.M.L., B.C. and J.J.; Formal Analysis, L.M.L.; Investigation, L.M.L., B.C., P.S.D. and J.J.; Resources, L.M.L. and J.J.; Data curation L.M.L., B.C., P.S.D. and J.J.; Writing—original draft, L.M.L., B.C., P.S.D. and J.J.; Writing—reviewing and editing, L.M.L., P.S.D. and J.J.; Project Administration, L.M.L., B.C. and J.J.; Funding acquisition, L.M.L. All authors have read and agreed to the published version of the manuscript.

Funding

This research was internally funded by the University of Michigan Office of the Vice President for Research (OVPR) Pandemic Relief Program. No external funding was received.

Institutional Review Board Statement

This study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of the University of Michigan-Flint (HUUM00206885), 3 November 2021.

Data Availability Statement

The dataset presented in this article are not readily available because the data are part of an ongoing study. Requests to access the raw data should be directed at the corresponding author.

Acknowledgments

We would like to thank Michelle Sahli for her statistical consultation role.

Conflicts of Interest

The authors declare no conflicts of interest.

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