I am scared too, there is so much uncertainty. I know it is risky to stay unvaccinated, but the vaccine is feeling riskier. If I am not vaccinated, how can I recommend it to others?
This was a front line worker and not an end-user sharing her apprehensions during our field research. Assuming that healthcare workers (HCWs) or front-line workers (FLWs) who are at the forefront of the battle against COVID-19 understand the risks and readily accept solutions to mitigate them may not be wise.
Source: www.un.org | Image: Homeline Media
In the past, globally, a few nations have experienced health epidemics such as HIV, Polio, Ebola, H1N1 but COVID-19 pandemic has presented a new and complex decision environment for many. Living through these times, individuals have been making decisions under extreme uncertainty and in an ambiguous environment with little or no control over outcomes. One such decision, a novel one, is that of the COVID-19 vaccine. Individuals with different demographic backgrounds and unique vulnerabilities have communicated hesitancy towards COVID-19 vaccines. While some refuse or hesitate to take the vaccine as it feels irrelevant to them in a low perceived risk environment, others may experience hot-state hesitancy due to the anticipated side-effects of the vaccine and delay their decision in the lack of urgency and yet others who do not trust the health system and communication from them. The studies prior to vaccine dissemination suggested high willingness among the population but subsequent data shows that there appears to be some resistance in the community for uptake.
During our research, what has been interesting is that this resistance is not just among the the community or end-users. Front line workers and health-care workers too appear to harbour some level of unfavourable COVID-19 vaccine sentiments.
During our time in the field, conducting the formative research in Pakistan, Burkina Faso, Kenya and Cote D’ Ivore, we spoke to frontline workers including healthcare providers, community health workers, nurses and vaccination staff. During these conversations we got a great insight into the interactions that community members have with them regarding the vaccination and existing barriers to vaccination. Along with that, the front line workers also opened about their experience of the pandemic, how COVID-19 has impacted their personal and professional lives and their sentiments towards the COVID-19 vaccines.
While conversing about their experiences of the pandemic, they shared situations in which they saw both younger and older people affected due to COVID-19, the constant fear they had in the initial days of the pandemic when they had to continue to work and maintain distance from their families. Some doctors even spoke about contracting COVID-19 more than once and the constant fear of being a threat to their families. Given their role as front line workers and their knowledge of diseases and viruses, most of them perceive the risk of COVID-19 and follow compliance measures to mitigate the risk. Since doctors, nurses and community health workers were at the maximum risk of contracting the virus, COVID-19 vaccines were first made available to them in all the countries around the world. They were among the first cohorts to make this decision and take the vaccine(s). Being at a high-risk of contracting the disease, it is safe to assume that the uptake and confidence on COVID-19 vaccine should be high enough among the HCWs and FLWs. But listening to their COVID-19 vaccine decision, it appears that they underwent a unique decision making process which was done in an extremely uncertain and fearful environment as they were one of the first individuals to be vaccinated in the world.
While many of the healthcare workers we spoke to shared a feeling of pride and safety in being vaccinated, there were some who had a different story to share. They shared their initial hesitation to being vaccinated and spoke about other colleagues who are still hesitant and avoid vaccination altogether.
Most front line workers trust the safety and efficacy of vaccines in general. But a smaller group of them feel that they may be at risk of being the guinea pigs for the COVID-19 vaccine roll out and therefore feel more in control by only following the compliance measures to mitigate the risk, resulting in delaying their decision to take the COVID-19 vaccine. With their existing understanding of the decades-long development and roll out of vaccines for other diseases, they further doubt the quick turnaround of the vaccine and do not feel confident about it. In the initial days of the vaccine roll out, like other community members, healthcare workers were displaying mild resistance and preferred to delay their decision to be vaccinated while waiting and watching. This was evident from the rate of uptake among the health fraternity in the initial months.
Misinformation in the community about vaccines being unsafe due to potential side effects, risk of infertility and death within two years also impacted the front line workers' vaccine decision.
Constant flow of such information combined with their family’s sentiments as a result of such misinformation results in negative anticipations against vaccination (loss of fertility and loss of life).
There is a lack of trust and confidence in the vaccines. In Burkina Faso and Cote D’ Ivore, vaccines causing infertility and death also leads to individuals feeling that vaccines are white men’s conspiracy against the black community and may be COVID-19 therefore is also a ploy. The existing distrust in the community towards the vaccines from White men has shown to also spill over to the healthcare workers. While they understand that COVID-19 is real, they do bring these theories within their consideration sets of information.
Even from those who have been vaccinated it was a case of low intrinsic motivation. Some of them communicated being vaccinated due to the system’s expectation of them and/or a work mandate. A healthcare worker shared his story of having to be vaccinated as the hospital needed all front line workers to be vaccinated. He is worried even after being vaccinated as the theories of infertility and death eventually seem to be real in the lack of these misinformations being debunked. Even after being vaccinated, the negative sentiments towards the vaccines continue to exist and he does not have the confidence to recommend vaccines to others . Some front line workers were also angry and regretted being vaccinated as they heard about some of this information about potential consequences after being vaccinated. These sentiments have the potential to have negative spillovers as FLWs/HCWs are seen as sources of trust by individuals in their health-seeking journey.
Like the others in the community, healthcare workers also make risk-reward trade offs to arrive at a vaccine decision, however, their list of risks and benefits also involve those that are informed by their role in the community, for eg. loss of identity if remained unvaccinated, pressure of being the flag bearer of taking preventative measures, etc. In developing nations, front line workers are an important and influential part of the health system. They have the maximum reach in the community and individuals trust them as they are the face of the health systems in local setups. While they constitute a major part of the population themselves, they also influence others in the community, making them an important part of the population to consider while thinking of interventions.