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 International Journal of Nursing Studies 131 (2022) 104241

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Addressing vaccine hesitancy and resistance for COVID-19 vaccines

Micah D.J. Petersa,b,c,d,∗
a
University of South Australia, Clinical and Health Sciences, Rosemary Bryant AO Research Centre, City East Campus | Centenary Building P4-32 North
Terrace, Adelaide, SA 5000, Australia
b
Faculty of Health and Medical Sciences, University of Adelaide, Adelaide Nursing School, Adelaide, SA, Australia
c
The Centre for Evidence-based Practice South Australia (CEPSA): A Joanna Briggs Institute Centre of Excellence, Australia
d
Australian Nursing and Midwifery Federation (ANMF) Federal Office, Australia

article info abstract

Article history: The COVID-19 vaccine rollout has had various degrees of success in different countries. Achieving high
Received 9 August 2021 levels of vaccine coverage is key to responding to and mitigating the impact of the pandemic on health
Received in revised form 22 March 2022
and aged care systems and the community. In many countries, vaccine hesitancy, resistance, and refusal
Accepted 28 March 2022
are emerging as significant barriers to immunisation uptake and the relaxation of policies that limit ev-
eryday life. Vaccine hesitancy/ resistance/ refusal is complex and multi-faceted. Individuals and groups
Keywords:
have diverse and often multiple reasons for delaying or refusing vaccination. These reasons include: so-
Vaccine [MeSH]
COVID-19 [MeSH] cial determinants of health, convenience, ease of availability and access, health literacy understandability
COVID-19 vaccines [MeSH] and clarity of information, judgements around risk versus benefit, notions of collective versus individual
SARS-CoV-2 [MeSH] responsibility, trust or mistrust of authority or healthcare, and personal or group beliefs, customs, or ide-
Anti-vaccination movement [MeSH] ologies. Published evidence suggests that targeting and adapting interventions to particular population
Vaccination refusal [MeSH] groups, contexts, and specific reasons for vaccine hesitancy/ resistance may enhance the effectiveness of
interventions. While evidence regarding the effectiveness of interventions to address vaccine hesitancy
and improve uptake is limited and generally unable to underpin any specific strategy, multi-pronged
interventions are promising. In many settings, mandating vaccination, particularly for those working in
health or high risk/ transmission industries, has been implemented or debated by Governments, decision-
makers, and health authorities. While mandatory vaccination is effective for seasonal influenza uptake
amongst healthcare workers, this evidence may not be appropriately transferred to the context of COVID-
19. Financial or other incentives for addressing vaccine hesitancy may have limited effectiveness with
much evidence for benefit appearing to have been translated across from other public/preventive health
issues such as smoking cessation. Multicomponent, dialogue-based (i.e., communication) interventions are
effective in addressing vaccine hesitancy/resistance. Multicomponent interventions that encompasses the
following might be effective: (i) targeting specific groups such as unvaccinated/under-vaccinated groups
or healthcare workers, (ii) increasing vaccine knowledge and awareness, (iii) enhanced access and con-
venience of vaccination, (iv) mandating vaccination or implementing sanctions against non-vaccination,
(v) engaging religious and community leaders, (vi) embedding new vaccine knowledge and evidence in
routine health practices and procedures, and (vii) addressing mistrust and improving trust in healthcare
providers and institutions via genuine engagement and dialogue. It is universally important that health-
care professionals and representative groups, as often highly trusted sources of health guidance, should
be closely involved in policymaker and health authority decisions regarding the establishment and im-
plementation of vaccine recommendations and interventions to address vaccine hesitancy.
© 2022 Elsevier Ltd. All rights reserved.

What is already known multiple reasons for either delaying/avoiding vaccination or re-
fusing vaccination entirely.
• Vaccine hesitancy/resistance/refusal is complex and multi- • Multicomponent, dialogue-based (i.e., communication)
faceted with individuals and groups having diverse and often interventions are effective in addressing vaccine hesi-
tancy/resistance.
∗
• Healthcare professionals and their representative groups should
Correspondence to: University of South Australia, Clinical and Health Sciences,
Rosemary Bryant AO Research Centre, City East Campus | Centenary Building P4-32
be closely involved in policymaker and health authority deci-
North Terrace, Adelaide, SA 50 0 0, Australia. sions regarding the establishment and implementation of vac-
E-mail address: [email protected] (M.D.J. Peters) cine recommendations.

https://doi.org/10.1016/j.ijnurstu.2022.104241
0020-7489/© 2022 Elsevier Ltd. All rights reserved.
2 M.D.J. Peters / International Journal of Nursing Studies 131 (2022) 104241

What this paper adds ing choices regarding whether to be vaccinated, with a recent
study finding counties in the regions of the United States with
• Mandatory vaccination is effective for seasonal influenza uptake a high percentage of Republican Party voters had significantly
amongst healthcare workers, but this evidence may not be ap- lower COVID-19 vaccination rates and higher numbers of COVID-
propriately transferred to the context of COVID-19 vaccination. 19 cases and deaths per 10 0,0 0 0 residents (Albrecht, 2022). This
• Evidence regarding the effectiveness of interventions to address study also provides a revealing review of the exogenous variables
vaccine hesitancy and improve uptake is limited and generally of race/ethnicity, educational attainment, and poverty in relation to
unable to underpin any specific strategy. political views in the United States and suggests that these factors
• Financial or other incentives for addressing vaccine hesitancy indirectly influence vaccination rates via their relationship with
may have limited effectiveness with much evidence for bene- people’s political views.
fit appearing to have been translated across from other pub- Since the emergence of vaccines (Durbach, 20 0 0), some have
lic/preventive health issues such as smoking cessation. highlighted the importance of getting vaccinated as a collective
responsibly to protect the health of the community and part of the
1. Introduction social contract (Korn et al., 2020), while others have raised con-
cerns regarding impositions on personal freedom, bodily autonomy,
In many countries, the rollout of COVID-19 vaccines has and creation or perpetuation unfair social hierarchies where those
been hampered by many factors including issues with afford- who are vaccinated are afforded greater freedom from pandemic
ability (Wouters et al., 2021), supply (Alam et al., 2021), storage restrictions than those who are not (Durbach, 20 0 0). In efforts
(Sun et al., 2022), resources (Feinmann, 2021), logistics (Mills and to encourage vaccination, many governments have set specific
Salisbury, 2021), public confusion (Mac et al., 2021), and political goals and timelines linking the relaxation of “lockdown” measures,
leaders and others promoting misinformation (Muric et al., 2021; cross-border travel, and restrictions that prevent many social and
Romer and Jamieson, 2021; Recio-Román et al., 2021). Many high- commercial activities with population-level vaccination status
income countries have now achieved relatively high two-dose vac- milestones (Prime Minister of Australia 2021; United Kindgom
cine coverage and are now progressing to third and even fourth- Government 2021; Government of Manitoba 2021). Many of these
dose administration in comparison to many low-middle income measures have been extremely unpopular, with many communi-
countries (LMICs) that have struggled to access vaccines and de- ties experiencing divisions between those who have, more or less,
ploy largescale vaccination rollouts. New variants of concern such supported restrictions and those who wish to see all restrictions
as Delta and Omicron are now emerging to threaten both highly removed and life return to “normal”. In August in Australia, the
vaccinated and under-vaccinated populations alike, due to greater Government announced a milestone to progressively ease COVID-
vaccine escape and immune system evasion ability. 19 restrictions once the eligible population had reached around 70
Another factor that has frequently taken centre stage in rela- percent vaccination coverage. At that time, only 41.4 percent of the
tion to national and global vaccination efforts is a slower than Australian population aged 16 years and older had received one
ideal uptake by community members, sometimes including health- dose of either of the Pfizer/Comirnaty (BNT162b2) or AstraZeneca
care professionals and workers themselves, who have ready ac- (ChAdOx1-S) vaccines, with 19.7 percent of the same population
cess to vaccines (Dror et al., 2020; Dubov et al., 2021). Peo- having received two doses (Prime Minister of Australia, 2021). At
ple’s decisions regarding vaccination are based on numerous fac- the time of writing, 94.9 percent of the eligible population aged
tors (Machingaidze and Wiysonge, 2021); convenience ease of 16 or older has now received at least two doses of an Australian
availability and access (Rosen et al., 2021), health literacy un- approved COVID-19 vaccination with attention now turning to the
derstandability and clarity of information (Lorini et al., 2018), administration of booster shots for eligible people (currently at
judgements around risk versus benefit (Patelarou et al., 2021; 66.5% of the eligible population) in the wake of the emergence of
Wagner et al., 2021), notions of collective versus individual respon- the Omicron variant and findings of waning vaccine effectiveness
sibility (Zia Sadique, 2006; Korn et al., 2020), trust/mistrust of au- and immune response (Australian Government Department of
thoritative institutions and healthcare (Quinn and Andrasik, 2021; Health, 2022). With many countries relaxing restrictions on travel,
Vergara et al., 2021), and personal or group beliefs, customs, or the Delta and Omicron variants have now become dominant in
ideologies (Agarwal et al., 2021). many contexts worldwide. Government responses to the spread of
Investigation and efforts to encourage improved vaccine uptake variants of concern has not been uniform or necessarily consistent.
preceded the SARS-CoV-2 pandemic and subsequent development Some governments have reintroduced restrictions on social and
of an array of vaccines (Butler and MacDonald, 2015), but possibly economic activity despite high vaccine coverage at a time when
now more than ever, a focus on increasing the number of vacci- it was previously anticipated that such limitations would be
nated individuals within jurisdictions and globally against COVID- significantly diminished. Others continue to reduce restrictions
19 has been driven by both concern for the health and wellbeing of despite increasing case numbers. Vaccine and immunity “pass-
the community as well as the desire to bring forward the end of ports” to allow people who have been vaccinated and/or who
many pandemic-related policies that restrict individual freedoms test positive for COVID-19 antibodies to return to more normal,
and economic activity (Sallam, 2021). Many governments have pro- pre-pandemic behaviours, including freer travelling and returning
moted vaccination as a social responsibility, particularly amongst to work have been considered, implemented, and widely debated
younger and otherwise healthy groups of people, who are rela- in many jurisdictions (Kofler and Baylis, 2020; Brown et al., 2021;
tively less likely to become seriously ill or die even without a Phelan, 2020; Spitale et al., 2022; Walkowiak et al., 2021). In many
vaccination (Zia Sadique, 2006). In contrast, in the highly politi- jurisdictions, vaccination status and the number of doses a person
cised world of the pandemic, parties and political figures have also must have to be considered “fully vaccinated” and thus eligible to
campaigned on the basis of protecting individuals’ freedoms from take advantage of reduced restrictions on activities such as travel
mandatory vaccination, as well as public and social health mea- or entry into hospitality venues or health and aged care facilities,
sures that have been deployed to protect communities against the has become a focus (Saban et al., 2021; Rubin, 2021). Using
spread of the virus. mandates to restrict unvaccinated people’s participation in com-
Governments and political power play an important role in munity life is not new, as different actions and impacts of vaccine
global and local issues around vaccine access, hesitancy, and re- mandates have been in place for some time, particularly regarding
sistance. Political views are a critical factor for many people mak- childhood immunisation and participation in childcare and school
 M.D.J. Peters / International Journal of Nursing Studies 131 (2022) 104241 3

(Attwell et al., 2018), and healthcare staff’s eligibility to work When discussing people’s decisions regarding whether to re-
(Haviari et al., 2015). These types of mandates and conse- ceive a vaccination (or permit someone under their care such as
quences for non-compliance have now extended into communities a child or dependant adult to be vaccinated), it is important to be
more widely are unsurprisingly controversial and hotly debated clear on the distinction between some key terms. ‘Vaccine hesitant’
(Hagan et al., 2022; Ioannidis, 2021). Amongst the many concerns is not the same as ‘vaccine resistant’ or as ‘anti-vax’ (Razai et al.,
and ethical issues in this area, is whether or not such mandates 2021). Even within these categories there are a range of issues and
and legislation designed to encourage vaccine uptake represents distinctions that must be unpacked in order to properly understand
coercion and whether such interventions appropriately address and account for the variety of human behaviours and beliefs.
people’s feelings of hesitancy or vaccine refusal. Confusing these distinct but related groups risks both failing
The sociodemographic factors that underpin vaccine hesitancy to understand or even empathise with alternative and sometimes
and resistance are both context- and time-specific as well as mul- quite reasonable perspectives and missing critical opportunities to
tifaceted and interlinked. Issues such as social determinants of address, engage, or even alleviate these people’s concerns or inter-
health, health inequality, socioeconomic dis/advantage, ethnicity, pretations (Bedford et al., 2018). Healthcare professionals, includ-
racism, exposure to mis/information, and access/convenience, are ing nurses who are at the frontlines of the COVID-19 vaccine ef-
all at play. Each of these factors being more or less dominant de- fort, provide care to a diverse range of community members and
pending upon time and place (Biswas et al., 2021; Aw et al., 2021; the delivery of empathetic, individualised person-centred care is
AlShurman et al., 2021; Joshi et al., 2021). Poverty is one factor enshrined in professional codes of practice. Establishing trust be-
that is strongly related to vaccine hesitancy, with persons living tween health providers and community members is vital to the
in poverty more likely to face language barriers and lack trust in delivery of appropriate and effective care. Addressing mistrust and
health experts (Howell and Fagan, 1988), as well as living in more ensuring genuine partnerships and shared decision-making under-
crowded and less sanitary conditions with poorer access to health- pins this. It is therefore vital that we better understand the per-
care (Chokshi, 2018). This also raises the important issue that while spectives and experiences of the patient/client and identify where
people from marginalised, impoverished, or disadvantaged back- and how safe, effective, and appropriate care can be delivered in
grounds might be more hesitant to be vaccinated, they are often the context of the vaccine roll-out.
also the communities that face the greatest risk and burden of dis- As noted above, an individual’s willingness/refusal to be vacci-
ease due to the sequelae of negative social determinants of health. nated exists on a continuum. Vaccine hesitancy could be defined
Vaccine hesitancy/resistance is inextricably linked with issues as closer to a “wait-and-see” approach regarding some people’s re-
around equity of vaccine access particularly in LMICs and amongst luctance to ‘get the jab’ as soon as possible (Rosenbaum, 2021b).
population groups with poorer access to healthcare and services A framework, based on data from high-income countries, suggests
(Machingaidze and Wiysonge, 2021; Moola et al., 2021). Many five core individual–level determinants for vaccine hesitancy: con-
members of these population groups have not been vaccinated fidence, complacency, convenience/constraints, risk calculation, and
due to severe resource shortages and poor access to vaccines. collective responsibility (Betsch et al., 2018; Wiysonge et al., 2021).
Recent evidence suggests that LMIC populations may be more Vaccine hesitant people could intend to get vaccinated in the fu-
willing to receive a COVID-19 vaccine than counterparts in high- ture, perhaps if certain conditions are met, but might avoid or de-
income United States and upper-middle income Russia (Solís Arce lay vaccine administration. People who are vaccine hesitant may
et al., 2021). These results indicate that prioritising vaccination be delaying receiving a vaccine because of inconvenience, unfamil-
in LMICs with populations who are willing to be vaccinated may iarity with new clinics and booking processes, or confusion regard-
be an effective approach to boosting worldwide vaccine coverage. ing whether or not they are eligible to receive one. Lockdowns im-
This is important, as low vaccine coverage in these settings is plemented in response to COVID-19 may also impact upon vaccine
known to be a precondition for the emergence of new variants hesitancy, with a recent Italian study finding that in comparison
including Delta and Omicron, which appear to be better able to to pre-lockdown phases, regardless of beliefs about vaccines, more
evade vaccine-associated immune responses, particularly without people were willing to be vaccinated for both COVID-19 and in-
a booster dose, or when a person has not been infected previously fluenza as risk perceptions rose (Caserotti et al., 2021). This high-
(Anderson et al., 2022; Flemming, 2022). lights how some people who are vaccine hesitant might be con-
Understanding and addressing vaccine hesitancy and resistance cerned or unaware of the emerging evidence for vaccine effective-
in local settings is important for nurses and other healthcare pro- ness and safety, or deem risk of illness for them or the people
fessionals, as they are often community members’ most accessible around them as too low to offset the potential for personal harm.
and trusted sources of healthcare information and guidance. This Interestingly, there is also evidence to suggest that vaccine hesitant
discussion paper summarises evidence regarding key issues around people may still accept vaccination while remaining vaccine hesi-
vaccine hesitancy and resistance and presents perspectives regard- tant, with a study from the United States finding that 60 percent
ing interventions for addressing resistance and hesitancy. The pa- of 1475 recently vaccinated adults reported some level of hesitancy
per also discusses how nurses and nursing organisations can act to including 10 percent who were still ‘very hesitant’ (Willis et al.,
respond to vaccine hesitancy and resistance. 2022). This is potentially significant in terms of addressing vaccine
hesitancy in already vaccinated populations in relation to second,
1.1. Vaccine hesitancy and resistance/refusal third, and possible future doses, as it highlights that perhaps not
every reason for a person to be hesitant needs to be resolved be-
While the World Health Organization (WHO) defines vaccine fore decision and behaviour changes can occur.
hesitancy to encapsulate both concepts of delay in acceptance and Some vaccine hesitant people will not be swayed by even
abject refusal, this broad conceptualisation might create further is- evidence-based information regarding the risk of harm from the
sues in gaining a clear understanding of what is a complex, and disease the vaccine is designed to prevent (Rosenbaum, 2021b).
often varied phenomena (MacDonald, 2015). While people’s views Partially, this may be explained by a lack of knowledge about the
on whether to a receive a vaccine and their subsequent action to vaccines, lower health literacy, or the understandably of and access
do so exists on a continuum from full acceptance to outright re- to evidence and information. Others may be highly educated and
fusal (MacDonald, 2015), it is within this spectrum that distinctions very health-literate, but have political views or beliefs that may in-
and differences become important in terms of working out how to fluence their willingness to be vaccinated. Vaccine hesitant people
address the attendant challenges (Jarrett et al., 2015). might have no particular opposition to the vaccines or medicine
4 M.D.J. Peters / International Journal of Nursing Studies 131 (2022) 104241

in general, but may be distrusting, fearful, or reluctant to access been proven to be safe or effective (Jolley and Douglas, 2014;
healthcare or social services more broadly due to past experience, Cookson et al., 2021). Some vaccine resistant people have been
discrimination, or marginalisation (Quinn and Andrasik, 2021). The found to be less likely to obtain information about the COVID-
impact of discrimination and marginalisation is an important con- 19 pandemic from traditional authoritative sources (Romer and
sideration for ethnic minorities and black, indigenous, and other Jamieson, 2021; Murphy et al., 2021). A very small minority of
people of colour (BIPOC) (Quinn and Andrasik, 2021; Razai et al., vaccine refusers might engage in active efforts to win over others
2021). A recent community-led ethnographic study in Sierra Leone though strategies that seek to spread ‘alternative facts’, conspir-
found that issues of trust/mistrust were closely linked to past ex- acy theories, or simply by focussing on reports of real or poten-
periences with the health system and workers and trepidation tial vaccine-related deaths and adverse events (van Stekelenburg
of having to pay unaffordable high prices (Enria et al., 2021). In et al., 2021). Social media is a common platform for this behaviour
Nigeria where vaccine hesitancy is a known issue, a recent study (Puri et al., 2020). People who are resistant or refuse vaccines out-
found that male gender, religion, ethnicity, and geographical loca- right might have the potential to be convinced otherwise, but this
tion to positively influence the willingness of Nigerians to get vac- is unlikely to be as easy as advising people who are vaccine hesi-
cinated against COVID-19 and that over 60 percent on Nigerians tant to become vaccinated.
would accept vaccination if recommended by healthcare workers
(Eze et al., 2021). Another study in the United States found that 1.2. Addressing vaccine hesitancy and resistance
black and Hispanic nursing home staff appeared to have signifi-
cantly worse COVID-19 vaccine uptake in comparison to their col- Widespread uptake of COVID-19 vaccines in all nations will be
leagues, but that addressing cultural sensitivities, accessibility to an important factor to bringing about the end of the pandemic
information sessions, and providing multilingual educational ma- (Solís Arce et al., 2021). Many countries with both high and low
terials may have reduced the disparity (Feifer et al., 2021). COVID-19 vaccine uptake and coverage are grappling with issues
In contrast to vaccine hesitancy, which might evolve into or co- around vaccine hesitancy and resistance. As noted, this is especially
exist with willingness to be vaccinated, vaccine resistance or re- pertinent with the emergence and rapid spread of new, highly
fusal (often termed ‘anti-vax’), then might be understood to re- transmissible variants that appear to be relatively unhindered by
fer to a more ingrained opposition to either COVID-19 vaccines less recent two-dose vaccine schedules. This can be dire in coun-
specifically, or vaccines (and indeed other medicines) in general tries with low vaccine coverage that typically have fewer resources
(Rosenbaum, 2021a). This isn’t to say, however, that an adamantly and significant challenges efficiently rolling out largescale vaccina-
vaccine resistant or person who is ‘antivax’ will never change their tion and booster doses.
mind. There are numerous recent media reports, personal stories, In an attempt to hasten the vaccine rollout and potentially sway
and suggested strategies regarding how to change the minds of vaccine hesitant/ refusing individuals to take up vaccines despite
people who are antivax (Ahmed, 2021). As with vaccine hesitant misgivings, many governments and decision makers have consid-
people, within the ranks of the ‘vaccine resistant’ are a diversity of ered or implemented vaccine mandates. Mandating COVID-19 vac-
beliefs, perceptions, and heuristics. cination has been a significant and controversial topic raising no-
As with vaccine hesitancy, vaccine refusal has existed since the table disputes between individual freedom of choice and the social
very first vaccines in the late 18th century, with the essence of good and community health (Zia Sadique, 2006). While the World
many arguments against vaccines and vaccination appearing rel- Health Organization has warned that mandating vaccines should
atively consistently (Succi, 2018; Grzybowski et al., 2017). Some be a last resort (World Health Organization (WHO) 2021), mandat-
vaccine resistant people might be unpersuaded by ‘the science’ ing vaccines does appear to be an effective way of enhancing vac-
or see vaccines as a legitimate threat to their health, wellbeing, cine uptake. A recent study found that campaigns for mandatory
or bodily or even personal integrity (Lunz Trujillo et al., 2020; influenza vaccination including a ‘vaccinate-or-wear-a-masque pol-
Whitehead et al., 2019; Agley and Xiao, 2021). Others may focus icy’ as well as mandatory declination (i.e. where healthcare work-
less on the vaccines themselves but more on distrust of the politi- ers must sign an official statement when refusing to be vaccinated)
cal or power machinations they see to be influencing governments reached vaccination coverage in healthcare workers of over 90 per-
and other people’s behaviour (Lin et al., 2020). Indeed, the explo- cent (Schumacher et al., 2021). Despite these results however, in
sion of social media access and availability of information both many cases such policies may be unfeasible or undesirable, par-
accurate and misleading, as well as patently false - especially in ticularly where the vaccines in question are not familiar seasonal
a period of extremely fast-paced evidence production, dissemina- influenza vaccines, but vaccines that are novel, provisionally ap-
tion and evolution – is one of the novel, recent ‘game changing’ proved, and widely and publicly debated.
conditions in the arena of vaccine willingness, hesitancy, and re- It could also be argued that mandating vaccination does not ac-
fusal (Puri et al., 2020; Wilson and Wiysonge, 2020; Benoit and tually address the core issues underlying vaccine hesitancy or re-
Mauldin, 2021). sistance, but instead marginalises vaccine hesitant/resistant people
Political views and political populism are also known to be as- further by pushing aside any opposition. Mandating vaccines could
sociated with vaccine hesitancy with both populist political groups also be seen to be coercive and intimidating, particularly for peo-
and some groups of people who are vaccine hesitant or antivax ple whose jobs and livelihoods may be on the line if they refuse on
sharing similar drivers including distrust in institutions, elites, and any basis, as well as for people with existing distrust of institutions
experts (Recio-Román et al., 2021; Albrecht, 2022; Bruine de Bruin and healthcare. Further, a systematic review found that mandating
et al., 2020). Indeed, populist parties have used vaccine-hesitant seasonal influenza vaccines was effective, but also that ‘soft man-
and antivax positions and sentiments to spread mistrust and divi- dates’ such as declination statements, increasing awareness, and
sion to advance political agendas and power despite findings that increased access were also effective, highlighting the need to ex-
perceptions of political influence could undermine vaccine accep- amine alternative approaches further (Lytras et al., 2016). Addition-
tance (Recio-Román et al., 2021; Bokemper et al., 2021). Beliefs ally, mandating vaccines when access and availability is so limited
that malevolent agendas, undue government or corporate control, that many individuals and groups cannot access them anyway is
or secret schemes underpin exhortations to get vaccinated might fraught with issues.
persuade some of these people against vaccination. Others may Addressing issues regarding convenience and complacency
be confused or concerned by the speed at which vaccines were might usefully occur though interventions that seek to ‘bring
developed and approved for use, and believe they cannot have vaccines to the people’ and ensure multiple, easily accessible
 M.D.J. Peters / International Journal of Nursing Studies 131 (2022) 104241 5

options for people to access vaccination services. Some exam- healthcare institutions than white participants (Armstrong et al.,
ples of these are: in-reach teams to bring vaccines to at risk 2008; Schwei et al., 2014). Results are not always consistent how-
but less mobile patients such as those in permanent accommo- ever, with findings also revealing no difference between ethnic
dation such as nursing homes (Feifer et al., 2021; Mor et al., groups in terms of trust in healthcare providers (Moran et al.,
2021), prisons (Costumbrado et al., 2012; Ramaswamy et al., 2016). A recent study suggests that localised approaches with edu-
2021), schools (Guarinoni and Dignani, 2021), mass vaccination cation and role-modelling from public officials and health author-
hubs (Signorelli et al., 2021), ‘pop-up’ clinics (Patil et al., 2021; ities are necessary to build public trust and enhance vaccine up-
Olusanya et al., 2021), and local general practices and pharmacies take (Vergara et al., 2021). Trust is a core element in the patient-
(Marwitz et al., 2021). Likewise, ensuring that vaccines can be co- healthcare provider relationship. It is fundamental to the deliv-
ordinated or administered by multiple health professions including ery of effective, appropriate care and to successful immunisation
nurses and pharmacists can be helpful where access to physicians initiatives. A 2016 review highlighted that healthcare providers
is limited (Ezeude et al., 2022). are amongst the community’s most influential and trusted sources
Evidence appears to suggest that multi-component interven- of advice regarding vaccination decision making (Paterson et al.,
tions may be more promising than single interventions for ad- 2016). This review recommended that because health professionals
dressing vaccine hesitancy. This would appear to make reasonable face considerable time and workload constraints, ensuring that ad-
sense, as it might better account for the complex factors and con- equate support is provided to ensure access to training information
ditions that underpin hesitancy and refusal in the first place. In and resources is vital. The authors also recommended that shared
2015 a review of 15 other reviews and meta-analyses found that involvement between health professionals, health authorities, and
limited evidence existed to suggest any specific approach to ad- policy makers is necessary to enhance trust between these groups.
dressing vaccine hesitancy/refusal would be effective and high- The working group of the Strategic Advisory Group of Experts
lighted that few interventions sought to actually target hesitant on Immunization (SAGE), that advises the World Health Organi-
individuals (Dubé et al., 2015). A 2015 systematic review found zation (WHO) on global vaccine policies and strategies regarding
limited evidence regarding strategies to address vaccine hesitancy issues including delivery of immunisation, determined that com-
(Jarrett et al., 2015). Thirteen studies were identified that provided munication is a tool that can both undermine and enhance vac-
moderate quality evidence for use of dialogue-based (e.g., social cine acceptance (MacDonald, 2015). Where communication is poor,
mobilisation, mass media, communication tool-based training for as with any other service, people may be more hesitant, how-
healthcare workers), non-financial incentives, and reminder/recall- ever ensuring clear, accurate, and understandable communication
based interventions. The review determined that multicompetent about vaccines can enhance people’s access to important informa-
and dialogue-based interventions were most effective, however tion about the vaccines and how to access them.
cautioned that strategies should be adapted to the target popu- Financial incentives to encourage behaviour change have been
lation, context, and specific reason/s for hesitancy (Jarrett et al., studied and found to be effective in other areas of public health
2015). including smoking cessation (Notley et al., 2019; Higgins et al.,
Within multicomponent interventions, the following specific 2012). Financial incentives have been suggested as a potential so-
interventions were found to lead to greater than 25 percent lution to enhancing vaccine uptake and willingness, however ev-
increases in vaccine uptake: targeting specific groups such as idence for the effectiveness such interventions remains limited
unvaccinated/under-vaccinated groups or healthcare workers, in- (Lytras et al., 2016; Volpp and Cannuscio, 2021). Some researchers
terventions to increase vaccine knowledge and awareness, en- have also suggested that financial incentives could be coercive and
hancements to access and convenience of vaccination, mandat- morally questionable particularly if struggling individuals or fam-
ing vaccination or implementing sanctions against non-vaccination, ilies feel bound to vaccinate simply to purchase food or pay rent
and engaging religious or other community leaders (Jarrett et al., (Largent and Miller, 2021).
2015). The review also found that education initiatives where new A 2021 study examined lottery incentives to influence vaccine
knowledge was embedded in routine practices such as hospital hesitant individuals (Taber et al., 2021). The study found that sev-
procedures was found to lead to greater than 20 percent improve- eral lottery structures were comparably effective, but that vaccina-
ment in knowledge, awareness, or attitudes towards vaccines. In- tion intentions did not differ across incentives and were strongly
terventions that were found to be least effective (less than 10 associated with baseline vaccine willingness. Participants tended
percent vaccine uptake) included: quality improvement activities to prefer options where less money was awarded to more people,
in vaccine clinics (e.g., increased hours, improved data collection), but the study also found that 41.9 percent of participants would
passive interventions (e.g., posters, websites), and incentive-based not vaccinate for any lottery-based monetary incentive. In another
interventions (which often focussed on general preventive health study, financial incentives were found to decrease likelihood of
rather than vaccination specifically). Reminder-recall interventions vaccination (i.e. $20 co-payment) and did not increase willingness
had variable, but positive results based on context. to vaccinate (Kreps et al., 2021).
As noted previously, trust and mistrust are important issues
in relation to people’s decisions regarding vaccination (González- 1.3. Nurses, nursing organisations, and addressing vaccine hesitancy
Melado and Di Pietro, 2021). Trust, and conversely mistrust, can and resistance
broadly refer to people’s expectations that their health, safety, and
best interests will be considered and accounted for in decisions Nurses and nursing organisations, including professional asso-
that impact them and in the healthcare interventions delivered by ciations and industrial trade unions, have an important role in
those caring for them. Trust is fundamental regarding the will- addressing vaccine hesitancy and resistance (Burden et al., 2021).
ingness of people and communities to follow guidance and ad- Nurses, together with other members of the healthcare profes-
vice both from governing institutions and authorities as well as sional team, are amongst the most trusted workforce groups in
healthcare providers. People who are less likely to trust author- the world and also comprise the largest proportion of the health
itative institutions and health providers due to past experiences workforce. This means that for most people, nurses are some of
both personal and systemic can be understandably unwilling to the most commonly encountered healthcare professionals and that
engage around receiving a new and relatively unfamiliar vaccine many look to nurses for guidance, information, and leadership re-
(Moran et al., 2016). Trust, also, is related to ethnicity/race, with garding health related topics and concerns including vaccination
studies finding that non-white participants often have less trust in (Solís Arce et al., 2021). A recent review highlighted that healthcare
6 M.D.J. Peters / International Journal of Nursing Studies 131 (2022) 104241

professionals in LMICs could be influential in reducing the impact the complexity and variability regarding many of the reasons and
of misinformation on vaccine hesitancy as well as through help- factors behind vaccine hesitance and resistance. It also appears vi-
ing members of the public, particularly those from lower socioeco- tal to understand that adapting messaging and communication to
nomic groups, women, and unmarried or lower educated people, the targeted population is of especial importance and that failure
gain better understandings of vaccine safety (Moola et al., 2021). to recognise the diverse and often reasonable concerns of differ-
Importantly, any measures to address vaccine hesitancy and resis- ent groups risks implementation of interventions that will fail to
tance should be locally tailored. Here is where healthcare staff ‘at be effective. A multicomponent intervention that encompasses the
the coal face’, who understand and engage with the community following may be effective: (i) targeting specific groups such as
first-hand, can be so useful. Healthcare providers must work to es- unvaccinated/under-vaccinated groups or healthcare workers, (ii)
tablish genuine and trusting relationships with their patients and increasing vaccine knowledge and awareness, (iii) enhance access
communities which can engender greater participation and will- and convenience of vaccination, (iv) mandating vaccination or im-
ingness to be vaccinated for the community good. plementing sanctions against non-vaccination, (v) engaging reli-
Around the world, local, international and global nursing or- gious or other community leaders, (vi) embed new vaccine knowl-
ganisations have been active and vocal in raising awareness and edge and evidence in routine practices such as hospital procedures.
advising governments, employers, and the public regarding COVID- Financial or other incentives for addressing vaccine hesitancy may
19, infection prevention and control measures and policy, and vac- have limited effectiveness with much evidence for benefit appear-
cination (International Council of Nurses (ICN), 2021). Indeed as ing to have been translated across from other public/preventive
the largest group of frontline healthcare professionals caring for health issues such as smoking cessation. In terms of designing and
and working with people with COVID-19, ensuring widespread vac- deploying interventions to enhance vaccine uptake, healthcare pro-
cine uptake along with adherence to public health and social mea- fessionals including nurses and their representative groups should
sures is vital for supporting the health and safety of the healthcare be closely involved in policymaker and health authority decisions
workforce during the pandemic (World Health Organizatin (WHO), regarding the establishment and implementation of vaccine recom-
2020). Nursing organisations and bodies have and should continue mendations.
to work with governments and local communities to develop tai-
lored strategies to address vaccine hesitancy and resistance and Declaration of Competing Interest
help inform and support their members and the nursing profession
more broadly to be active in working to address vaccine hesitancy None.
and resistance.

1.4. Conclusion Funding

The COVID-19 pandemic and attendant vaccine rollout is an No external funding.

unprecedented public health and logistical phenomenon. Address-
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