COVID-19 vaccination acceptance and hesitancy in health and care workers and the general population: a systematic review and policy recommendations

doi:10.21203/rs.3.rs-3136695/v1

Introduction: The COVID-19 pandemic challenged the scientific community to find and develop a vaccine to fight the disease. However, and despite the vaccines developed thus far, problems with achieving high vaccine coverages have emerged, even among high-risk groups such as health and care workers (HCW). The lack of experience with such extensive vaccination created knowledge gaps in health policy and multisector decisions worldwide.

Objective: This systematic review aims to examine factors that influence HCW's adherence to COVID-19 vaccination and national policies to vaccinate the HCW and other target groups.

Methods: Searches were performed in the PubMed, Embase, Scopus, CINAHL, Web of Science, Lilacs, and WHO databases, besides Google Scholar for grey literature. The eligibility criterion for inclusion was being a member of the HCW. Vaccination was the target intervention, and the COVID-19 pandemic was the context. Qualitative synthesis used a meta-aggregation approach.

Results: Nineteen articles were included in the review, with study samples varying from 48 to 5,708 participants. Most of the evidence came from cross-sectional and qualitative studies. The main findings were related to vaccine hesitancy rather than acceptance. Factors associated with HCW vaccine hesitancy included subjective feelings such as safety concerns, related to rapid vaccine development, and insufficient testing. Non-adherence to vaccination by HCW can contribute to vaccine hesitancy in the general population. Countries have adopted few public policies to address this problem, and the main concern is whether to enforce vaccination and the extent to which measures are legal. Conclusion: Despite the large number of studies identified in the review, the quality of the evidence base remains weak. Skepticism, mistrust, and hesitancy toward vaccination are global issues that can jeopardize vaccination coverage. Governments need guidance to develop gender-specific policies to inform HCW and the public about the need to adhere to vaccination in the current and future pandemic scenarios.

COVID-19

vaccination coverage

vaccine hesitancy

vaccination refusal

health and care workers.

The COVID-19 pandemic is an unprecedented public health emergency that has challenged the scientific community to develop mitigating strategies including vaccines successfully overcome the emergency. COVID-19 vaccine deployment has revealed the additional need to develop adequate means to achieve vaccine coverage. Low-income countries (LIC) were unable to obtain sufficient vaccines to immunize their entire populations. Despite increased access to vaccine, high- and middle-income countries (MIC) have faced policy indecisiveness in managing their health and care systems during the pandemic (1).

The global consequences of the COVID-19 pandemic are still challenging countries. The World Health Organization (WHO) reported a total of 628,346,704 cases and 6,573,968 deaths from the disease from 2019 to November 3, 2022. United States of America (USA), Brazil, India, Russia, and Mexico have the highest absolute numbers of deaths (2). Health and care systems have thus sought various alternatives to control the pandemic.

The most promising approach is to provide for the development of immunity in target groups and the general population initially through vaccination strategies to reduce the number of seriously infected people and case-fatality, subsequently scaling up the strategy to achieve population immunity. Between 2020 and2021 in LIC due to the lack of vaccines, the threats associated with COVID-19 and the various SARS-CoV-2 variants were a concern. Thus, in addition to other measures to prevent infection with the novel coronavirus, it is crucial to vaccinate both the general population and health and care workers (HCW) that perform vaccination and provide other health and care services.

A healthy health workforce is essential for health systems´ resilience and effectiveness, as HCW actions determine the efficient use of other resources. The HCW is thus central to the elaboration of health policies, including for COVID-19 (3). The way countries deal with the COVID-19 crisis depends greatly on the effective protection and deployment of the HCW. Occupational exposure to the virus is high in the HCW, and infected HCW can transmit SARS-CoV-2 to patients and their family members (4). Many measures can and must be taken to prepare the HCW to defeat the pandemic (5).

HCW are at high risk of occupational SARS-CoV-2 exposure and transmission, which prioritizes them for early COVID-19 vaccination. However, there has been an alarmingly high rate of COVID-19 vaccine hesitancy in the HCW. Recent evidence suggests that refusal to be vaccinated is associated with concerns about efficacy, safety, and the unprecedented fast-track vaccine production process (6). Since HCW serve as role models of appropriate preventive health behavior for the public at large, refusal by significant numbers of the HCW to be vaccinated against COVID-19 may also signal danger for the population (7) and contribute to widespread vaccine hesitancy. Vaccine hesitancy is a significant barrier to vaccine uptake and the achievement of collective immunity via vaccination (4).

Despite available data on the safety and effectiveness of the COVID-19 vaccines, skepticism, mistrust, and hesitancy are global problems. The unvaccinated portion of the population can prevent achieving collective immunity via vaccination (8). As discussed in this article, the overall impact on society and the factors that can explain non-vaccination have been explored in the literature in the last two years. Numerous factors can lead to low vaccination coverage in the general population, such as weak physician-patient communication, gaps in COVID-19 vaccine knowledge, perceived susceptibility, and perceived severity of the vaccine´s side effects (9). The lack of previous experience with a global vaccination campaign of this magnitude created a knowledge gap that still needs to be addressed to inform health policies and multisector decisions that can affect vaccine uptake worldwide.

This systematic review is based on four questions (Box 1) and aims to elucidate factors that influence HCWs` adherence to vaccination and national policies to cover health personnel and the population at large with COVID-19 vaccination.

Box 1. Review questions

The protocol of the present study was registered in PROSPERO database CRD42022325111 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=325111)

The PICo search tool (Population, Intervention/phenomenon of interest, Context) was used for the questions and data extraction to perform this systematic review (10).

Eligibility criteria

Population

The review included all studies in which participants were general or target population or health and care workers.

Intervention/Phenomenon of interest

The systematic review focused on research policies, barriers, and enablers for COVID-19 vaccination coverage, performance, and productivity.

Context

The context was the COVID-19 pandemic and vaccination of the HCW and the general or target population.

The inclusion criteria follow the PICo guidelines (Annex 1). The bibliographic and grey literature included databases, articles, and internet pages. The selected studies included systematic reviews, quantitative observational studies (i.e., cohort, case-control, cross-sectional), mixed methods, and qualitative studies published in English, French, Hindi, Portuguese, Italian, or Spanish. The target outcomes comprised policies, strategies, and interventions adopted in countries and mechanisms to improve the vaccination team´ performance and productivity, as well as strategies to achieve vaccination coverage of the respective population groups. We selected articles published between January 1^st, 2020, and March 31^st, 2022.

The eligibility criteria were first applied to the title and abstract/executive summary or introduction of the studies and, if met, applied again to the full texts (Annex 2). The full text was assessed for eligibility in case no abstract or equivalent was available.

Information sources and search strategy

The following databases were searched for this review: MEDLINE-PubMed, Embase, Scopus, Latin American and Caribbean Health Sciences Literature, and Web of Science. The World Health Organization Database and Google Scholar were adopted for the grey literature. The controlled vocabularies for the health area DeCs (Descriptors in Health Sciences), MeSH (Medical Subject Headings), and Emtree (Embase Subject Headings) were consulted to retrieve findings. Each review question had a specific search strategy per database and development by a librarian with expertise in systematic reviews. Annex 3 provides the entire search strategies.

Selection of studies

Endnote was used in the selection process to collect, organize, and manage references retrieved by the searches in the various databases (11). Once this phase was complete, we uploaded the references file to Rayyan (12). Two researchers (APS and LC) performed the selection independently, first by reading titles and abstracts and then by evaluating the full texts using the Rayyan program. Differences were discussed with a third researcher until a consensus was reached.

Eligibility and exclusion criteria were first applied to the abstracts of the retrieved documents, independently by at least two reviewers. When no abstract was available, the criteria were applied to the executive summary or the articles´ introduction.

When eligibility criteria were met, documents were selected for full-text analysis. In this phase, the eligibility and exclusion criteria were applied again, and if they were met, relevant data were then extracted from the document. In case of disagreement, a discussion between the two reviewers was done, and a third reviewer was consulted. Kappa statistics were computed to assess inter-reviewer agreement and the quality of this process. Kappa inter-reviewer agreement was 9.4^[1](13).

Inclusion of studies followed PRISMA guidelines (14): including the number of documents retrieved, number of duplicates, number of documents screened for abstracts or the equivalent, number of documents included for full-text analysis, number of excluded documents during full-text analysis, and number of documents for data extraction.

Data extraction

Data extraction from the included studies was randomly distributed between two reviewers and was performed using a spreadsheet in the REDCap software (15) . Tables 1 and 2 show the information extracted from the selected articles, including author, year, country, title, language, journal, study design and sample. There was a particular concern in identifying gender specific aspects referred to in the data. The findings are showed in Tables 3 and 4.

Assessment of bias risk

To assess the risk of bias in the included studies, we used the GRADE CERQual tool (Confidence in Evidence from Reviews of Qualitative research) for qualitative studies (16).

The reviewers used an electronic form of the GRADE-CERQual, developed in RedCap and specific to the study design (Annex 4).

Data synthesis

Qualitative synthesis using a meta-aggregation approach for each research question, organized within each question per outcome and each outcome per type of study.

We identified 29 texts, all in English, which met the inclusion and quality criteria for data extraction. After the two reviewers critically appraised the 29 full texts, ten were excluded from the assessment of findings and degree of confidence (1 failed to meet the study design criteria (opinion report), 4 were news articles and 5 weren’t clear about the methods). Figure 2 illustrates the entire selection process.

Quantitative and qualitative data extraction

The number of articles identified from the databases, disagreement between the two researchers on the sensitivity test, and reasons for exclusion of articles per each review question are showed in Annex 5. Some studies addressed more than one review question, so absolute numbers are listed according to the reasons for each question. The reasons for exclusion of the articles are in Annex 6.

After full text reading twelve of the included studies were cross-sectional surveys, five were qualitative, and two were systematic reviews. Years of publication were 2021 (n=10) and 2022 (n=9). Some publications answered more than one review question, and there were few studies about policies, regulations, and mechanisms to improve vaccination teams’ productivity and performance.

The studies covered 14 countries - USA (7), Italy (2), Turkey (2), Bahrain (1), Hong Kong (1), Israel (1), India (1), Korea (1), Mongolia (1), and the United Kingdom (UK) (1). There were no low or middle-income countries (MIC) or any from the Southern Hemisphere. There was only one multinational study with “Arabian countries”^{^[2]}, “European countries”^{^[3]}and “other countries”^{^[4]}(6).

Gender specific issues are addressed only in four of the papers (6,9,19,24).

Table 1 shows the data extraction from the included studies about general or target population.

Table 1 – General/target population - data extraction from included studies
Author, Year	Country	Title	Language	Journal	Study Design	Sample (population or studies)
Population intention for vaccination and refusal cause
*Han Zheng, Shaohai Jiang, Qiaofei Wu, 2022	USA	Factors influencing COVID-19 vaccination intention: The roles of vaccine knowledge, vaccine risk perception, and doctor-patient communication	English	Patient Education and Counseling	Cross-sectional	800
Population acceptance, barriers and access to vaccines
*Abba-Aji, Mohammed; Stuckler, David; Galea, Sandro; McKee, Martin, 2022	Turkey	Ethnic/racial minorities’ and migrants’ access to COVID-19 vaccines: A systematic review of barriers and facilitators	English	Journal of Migration and Health	Systematic review	33 studies
*Al-Metwali, B Z; Al-Jumaili, A A; Al-Alag, Z A; Sorofman, B., 2022	Israel	Exploring the acceptance of the COVID-19 vaccine among health care workers and the general population using the health belief model	English	J Evaluation in Clinical Practice	Cross-sectional	1680
Strategy for covering the population
Abou Leila, Rabih; Salamah, Mustafa; El-Nigoumi, Sarah, 2021	Bahrain	Reducing COVID-19 Vaccine Hesitancy by Implementing Organizational Intervention in a Primary Care Setting in Bahrain	English	Curreus	Interviews	193

*Participants are both population and HCW

Table 2 shows the data extraction from the included studies about Health and Care workers

Table 2 –Health Care workers - data extraction from included studies
Author, Year	Country	Title	Language	Journal	Study Design	Sample (population or studies)
HCW intention for vaccination, acceptance and refusal motivation
*Han Zheng, Shaohai Jiang, Qiaofei Wu, 2022	USA	Factors influencing COVID-19 vaccination intention: The roles of vaccine knowledge, vaccine risk perception, and doctor-patient communication	English	Patient Education and Counseling	Cross-sectional	800
*Al-Metwali, B Z; Al-Jumaili, A A; Al-Alag, Z A; Sorofman, B., 2022	Israel	Exploring the acceptance of the COVID-19 vaccine among healthcare workers and the general population using the health belief model	English	J Evaluation in Clinical Practice	Cross-sectional	1680
HCW Attitudes towards vaccination
Manby, Louisa; Dowrick, Anna; Karia, Amelia; Maio, Laura; Buck, Caroline; Singleton, Georgina; Lewis-Jackson, Sasha; Uddin, Inayah; Vanderslott, Samantha; Martin, Sam; Vindrola-Padros, Cecilia, 2022	UK	Healthcare workers’ perceptions and attitudes towards the UK’s COVID-19 vaccination program: a rapid	English	BMJ Open	Interviews	48
Ozgur Sema Aci, Ozlem Kackin,Selver Karaaslan , Emre Ciydem, 2022	Turkey	A qualitative examination of the attitudes of healthcare workers in Turkey regarding COVID-19 vaccines	English	International Journal of Nursing Knowledge	Interviews	36
Poon, Paul Kwok Ming; Zhou, Weiju; Chan, Dicken Cheong Chun; Kwok, Kin On; Wong, Samuel Yeung Shan 2021	China (Hong Kong)	Recommending COVID-19 Vaccines to Patients: Practice and Concerns of Frontline Family Doctors	English	Vaccines	Cross-sectional	312
Mei Li, Yue Luo, Roger Watson,Yu Zheng, Jianlan Ren, Jian Tang, Yanhua Chen, 2021	USA	Healthcare workers’ (s) attitudes and related factors towards COVID-19 vaccination: a rapid systematic review	English	Post Grade Med J	Systematic review	13 studies
Carpenter, Delesha M.; Hastings, Tessa; Westrick, Salisa; Mashburn, Patricia; Rosenthal, Meagen; Smith, Megan; Kiser, Stephanie; Gamble, Abigail; Brewer, Noel T; Curran,Geoffrey. 2022	USA	Rural community pharmacists’ ability and interest in administering COVID-19 vaccines in the Southern United States	English	Journal of the American Pharmacists Association	Cross-sectional	69
HCW vaccination hesitancy reasons
Toth-Manikowski, Stephanie M.; Swirsky, Eric S.; Gandhi, Rupali; Piscitello, Gina 2022	USA	COVID-19 vaccination hesitancy among health care workers, communication, and policy-making	English	American Journal of Infection Control	Cross-sectional	1974
Qunaibi, E; Basheti, I; Soudy, M; Sultan, I , 2021	Multinational	Hesitancy of Arab Healthcare Workers towards COVID-19 Vaccination: A Large-Scale Multinational Study	English	Vaccines	Cross-sectional	5708
Ashok, N; Krishnamurthy, K; Singh, K; Rahman, S; Majumder, M A A 2021	India	High COVID-19 Vaccine Hesitancy Among Health care Workers: Should Such a Trend Require Closer Attention by Policymakers?	English	Curreus	Cross-sectional	264
Harrison, Jill; Berry, Sarah; Mor, Vince; Gifford, David, 2021	USA	“Somebody Like Me”: Understanding COVID-19 Vaccine Hesitancy among Staff in Skilled Nursing Facilities	English	Journal of the American Medical Directors Association	Focus Group	58
Strategies to support HCW vaccination
Giannitrapani, Karleen F.; Brown-Johnson, Cati; Connell, Natalie B.; Yano, Elizabeth M.; Singer, Sara J.; Giannitrapani, Susan N. Thanassi, Wendy; Lorenz, Karl A., 2022	USA	Promising Strategies to Support COVID-19 Vaccination of Healthcare Personnel: Qualitative Insights from the VHA National Implementation	English	Journal of General Internal Medicine	Interviews	43
Kim, Min Hyung; Son, Nak Hoon; Park, Yoon Soo; Lee, Ju Hyun; Kim, Da Ae; Kim, Yong Chan 2021	Korea	Effect of a hospital-wide campaign on COVID-19 vaccination uptake among healthcare workers in the context of raised concerns for life-threatening side effects	English	Plos One	Cross-sectional	837
Policies for covering HCW vaccination
Pitini, Erica; Baccolini, Valentina; Rosso, Annalisa; Massimi, Azzurra; De Vito, Corrado; Marzuillo, Carolina; Villari, Paolo 2021	Italy	How Public Health Professionals View Mandatory Vaccination in Italy—A Cross-Sectional Survey	English	Vaccines	Cross-sectional	1350
Riccò, Matteo; Ferraro, Pietro; Peruzzi, Simona; Balzarini, Federica; Ranzieri, Silvia 2021	Italy	Mandate or Not Mandate: Knowledge, Attitudes, and Practices of Italian Occupational Physicians towards SARS-CoV-2 Immunization at the Beginning of Vaccination Campaign	English	Vaccines	Cross-sectional	166
Baumer-Mouradian, Shannon H.; Collins, Stacey; Lausten, Thomas; Pohl, Cecile; Sisney, Mary; Khare, Smriti; Ose, Megan; Roe, Jennifer; Reilly, Chelsi; Gutzeit, Michael, 2021	USA	Urgent COVID-19 Vaccination of Healthcare Workers via a Quality Improvement Initiative	English	Pediatric Quality & Safety	Cross-sectional	3921
Turbat, Battsetseg; Sharavyn, Bold; Tsai, Feng Jen 2022	Mongolia	Attitudes towards Mandatory Occupational Vaccination and Intention to Get COVID-19 Vaccine during the First Pandemic Wave among Mongolian Healthcare Workers: A Cross-Sectional Survey	English	International Journal of Environmental Research and Public Health	Cross-sectional	238

*Participants are both population and HCW

Table 3 - List of the general or target population studies´ findings and details of the GRADE assessment.

Table 3– GRADE CERQual Assessment
Author/Year	Title	Study design	Findings	Evidence	Summary assessment
*Han Zhenga et al., 2022	Factors influencing COVID-19 vaccination intention: The roles of vaccine knowledge, vaccine risk perception, and doctor-patient communication	Cross sectional	First, susceptibility to COVID-19 vaccine side effects was negatively associated with vaccination intention, whereas perceived severity did not show any significant impact. Second, vaccine-related knowledge was not directly related to vaccination intention, but it had an indirect and positive effect on vaccination intention via decreasing perceived susceptibility. Third, doctor-patient communication strengthened the negative effect of vaccine knowledge on perceived susceptibility and severity. Practical implications: Government agencies should actively emphasize the effectiveness and importance of vaccination.	Moderate Confidence	In this cross-sectional study, the criteria for inclusion in the sample were clear. Participants were recruited from an online panel managed by the survey company. The sample was small, and quota sampling was used to ensure that the distribution reflected the national profile. Only people with internet access were able to participate in the study. Using an online tool, the study was able to include more participants. The findings, data, and phenomena were coherent. The study was developed at a relevant time, in the early stage of vaccination programs in the United States. The study proposed a nationwide vision but presents a limitation in the representativeness of the participants. The strategy can be used by other researchers, and the results support vaccination uptake. The main findings show evidence regarding the impact of perceived susceptibility to COVID-19 vaccine side effects on vaccination intention in a sample of American adults. The findings also suggest that health professionals could help reduce the perceived risk associated with vaccine´s side effects in the public at large. Another important finding is doctor-patient communication, which plays a crucial role in facilitating vaccination intention.
*Abba-Aji et al., 2022	Ethnic/racial minorities’ and migrants’ access to COVID-19 vaccines: A systematic review of barriers and facilitators	Systematic review	Of a total of 248 studies screened, 33 met the criteria and were included in the final sample. 31 of the included studies were conducted in high-income countries, including USA (n = 17 studies), UK (n = 10), Qatar (n = 2), Israel (n = 1), and France (n = 1). One study was in an upper middle-income country, China (n = 1), and another covered multiple countries (n = 1). 26 studies reported outcomes for ethnic minorities, while 9 studies reported on migrants. Most of the studies were quantitative cross-sectional (n = 24) and ecological studies (n = 4). The remaining were qualitative (n = 4) and mixed methods (n = 1). There was consistent evidence of high levels of COVID-19 vaccine hesitancy among Black/Afro-Caribbean groups in the USA and UK, while studies of Hispanic/Latino populations in the USA and Asian populations in the UK provided mixed evidence, with levels that were higher, lower, or the same as their White counterparts. Asians in the USA had the highest COVID-19 vaccine acceptance compared to other ethnic groups. There was higher vaccine acceptance among migrant groups in Qatar and China than in the general population. However, migrants to the UK experienced barriers to vaccine access, mainly attributed to language and communication issues. Lack of confidence, mainly due to mistrust of government and health systems coupled with poor communication were the main barriers to vaccine uptake among Black ethnic minorities and migrants.	High confidence	The study is about migrants' access to vaccination in many countries. It consists of a systematic review with a clear methodology and coherence, adequacy, and relevance in all points of the assessment. The study is clear, rich in details, and useful for government politics.
*Al-Metwali et al., 2021	Exploring the acceptance of the COVID-19 vaccine among healthcare workers and the general population using the health belief model	Cross sectional	A total of 1,680 completed surveys were received. Mean age was 31.2 ± 9.9 years, with 53.0% females and 47.0% males. The largest group was HCWs (45.7%), followed by the general population (37.5%) and university students in health fields (16.8%). The findings expressed some hesitancy to COVID-19 vaccination, with an acceptance rate of 61.7%. HCWs perceived significantly higher susceptibility and severity of COVID-19 infection compared to the general population. HCWs were significantly more likely than the general population to receive the COVID-19 vaccine. Concerns with proper storage were the main barrier to receiving the vaccine. Regression analysis indicated eight factors significantly associated with willingness to receive the COVID-19 vaccine: Preventive measures, perceived benefit, perceived barriers, cue to action, subjective norm, support for vaccination in general, and having received a flu vaccine previously.	High confidence	The method is clear, and the researchers used an appropriate tool. The HBM successfully predicted the factors influencing people's acceptance of vaccination against COVID-19. Coherence between the target phenomenon, data, and findings. Data are consistent with the interest described in the findings. The sample size is small, and most of the respondents were from Baghdad, not representing the entire population of Iraq.
Abou Leila et al., 2021	Reducing COVID-19 Vaccine Hesitancy by Implementing Organizational Intervention in a Primary Care Setting in Bahrain	Interviews	There were 665 hesitant patients before the intervention. However, after the intervention, the number decreased to 193 patients, and the control chart revealed a reliable process. The percentage of recommendations by physicians increased from 1% to 51% after 19 weeks of implementation and with a controlled process. Rectifying process barriers and upgrading physicians' skills would improve the COVID-19 vaccine counseling rate, and tailored communication would reduce the hesitancy rate. Nevertheless, the study was constrained by lack of information on the impact of social media and national measures on patients' decisions.	High confidence	The method's development is clear and well done. The study does not present methodological limitations. It is well designed, the participants' selection is clear, and data collection and analysis follow best practices. The study has no ambiguity in the data, and the findings are clear. Both qualitative and quantitative data are clear and detailed. The theme is relevant and developed coherently.

*Participants are both population and HCW

Table 4 - List of the HCW studies´ findings and details of the GRADE assessment..

Table 4– GRADE CERQual Assessment
Author/Year	Title	Study design	Findings	Evidence	Summary assessment
*Han Zhenga et al., 2022	Factors influencing COVID-19 vaccination intention: The roles of vaccine knowledge, vaccine risk perception, and doctor-patient communication	Cross-sectional	First, susceptibility to COVID-19 vaccine side effects was negatively associated with vaccination intention, whereas perceived severity did not show any significant impact. Second, vaccine-related knowledge was not directly related to vaccination intention, but it had an indirect and positive effect on vaccination intention via decreasing perceived susceptibility. Third, doctor-patient communication strengthened the negative effect of vaccine knowledge on perceived susceptibility and severity. Practical implications: Government agencies should actively emphasize the effectiveness and importance of vaccination.	Moderate Confidence	In this cross-sectional study, the criteria for inclusion in the sample were clear. Participants were recruited from an online panel managed by the survey company. The sample was small, and quota sampling was used to ensure that the distribution reflected the national profile. Only people with internet access were able to participate in the study. Using an online tool, the study was able to include more participants. The findings, data, and phenomena were coherent. The study was developed at a relevant time, in the early stage of vaccination programs in the United States. The study proposed a nationwide vision but presents a limitation in the representativeness of the participants. The strategy can be used by other researchers, and the results support vaccination uptake. The main findings show evidence regarding the impact of perceived susceptibility to COVID-19 vaccine side effects on vaccination intention in a sample of American adults. The findings also suggest that health professionals could help reduce the perceived risk associated with vaccine´s side effects in the public at large. Another important finding is doctor-patient communication, which plays a crucial role in facilitating vaccination intention.
*Abba-Aji et al., 2022	Ethnic/racial minorities’ and migrants’ access to COVID-19 vaccines: A systematic review of barriers and facilitators	Systematic review	Of a total of 248 studies screened, 33 met the criteria and were included in the final sample. 31 of the included studies were conducted in high-income countries, including USA (n = 17 studies), UK (n = 10), Qatar (n = 2), Israel (n = 1), and France (n = 1). One study was in an upper middle-income country, China (n = 1), and another covered multiple countries (n = 1). 26 studies reported outcomes for ethnic minorities, while 9 studies reported on migrants. Most of the studies were quantitative cross-sectional (n = 24) and ecological studies (n = 4). The remaining were qualitative (n = 4) and mixed methods (n = 1). There was consistent evidence of high levels of COVID-19 vaccine hesitancy among Black/Afro-Caribbean groups in the USA and UK, while studies of Hispanic/Latino populations in the USA and Asian populations in the UK provided mixed evidence, with levels that were higher, lower, or the same as their White counterparts. Asians in the USA had the highest COVID-19 vaccine acceptance compared to other ethnic groups. There was higher vaccine acceptance among migrant groups in Qatar and China than in the general population. However, migrants to the UK experienced barriers to vaccine access, mainly attributed to language and communication issues. Lack of confidence, mainly due to mistrust of government and health systems coupled with poor communication were the main barriers to vaccine uptake among Black ethnic minorities and migrants.	High confidence	The study is about migrants' access to vaccination in many countries. It consists of a systematic review with a clear methodology and coherence, adequacy, and relevance in all points of the assessment. The study is clear, rich in details, and useful for government politics.
*Al-Metwali et al., 2021	Exploring the acceptance of the COVID-19 vaccine among healthcare workers and the general population using the health belief model	Cross-sectional	A total of 1,680 completed surveys were received. Mean age was 31.2 ± 9.9 years, with 53.0% females and 47.0% males. The largest group was HCWs (45.7%), followed by the general population (37.5%) and university students in health fields (16.8%). The findings expressed some hesitancy to COVID-19 vaccination, with an acceptance rate of 61.7%. HCWs perceived significantly higher susceptibility and severity of COVID-19 infection compared to the general population. HCWs were significantly more likely than the general population to receive the COVID-19 vaccine. Concerns with proper storage were the main barrier to receiving the vaccine. Regression analysis indicated eight factors significantly associated with willingness to receive the COVID-19 vaccine: Preventive measures, perceived benefit, perceived barriers, cue to action, subjective norm, support for vaccination in general, and having received a flu vaccine previously.	High confidence	The method is clear, and the researchers used an appropriate tool. The HBM successfully predicted the factors influencing people's acceptance of vaccination against COVID-19. Coherence between the target phenomenon, data, and findings. Data are consistent with the interest described in the findings. The sample size is small, and most of the respondents were from Baghdad, not representing the entire population of Iraq.
Manby et al., 2022	Healthcare workers’ perceptions and attitudes towards the UK’s COVID-19 vaccination program: a rapid	Interviews	Uncertainty about the long-term safety of vaccines and efficacy against mutant strains made it difficult for HCWs to balance the benefits against the risks of vaccination. HCWs felt that government decisions on vaccine rollout had not been supported by evidence-based science, and this impacted their level of trust and confidence in the program. The online spread of misinformation also impacted HCWs' attitudes towards vaccination, particularly among junior-level and black, Asian, and minority ethnic (BAME) HCWs. Most HCWs felt encouraged to promote vaccination for their patients, and the majority said they would advocate vaccination or engage in conversations about vaccination with others when relevant.	Moderate Confidence	The aim was to provide a nationwide study. The sample is small and does not represent the entire country. Few junior-level and Black, Asian, and minority ethnic (BAME) HCWs were interviewed. The sample and setting are not consistent with the objective. The study is highly coherent, and the adequacy is suitable. HCWs are the focus of the study. However, the nationwide scope was not represented, with only 2 Health care facilities.
Ozgur et al., 2022	A qualitative examination of the attitudes of Health care workers in Turkey regarding COVID-19 vaccines	Interviews	Most healthcare workers participating in the study were male and married, with an average age of 34 ± 19 years. In addition, 52.8% participants worked in a state hospital, the duration of their working lives was 11.31 ± 7.95 years, and the duration of their providing care to patients diagnosed with COVID-19 was 4.25 ± 5.73 months. Turkish healthcare workers´ attitudes toward the COVID-19 vaccine were divided into three themes: "influencing factors," "priority group", and "trust." Vaccine hesitancy can be addressed by careful attention to the application of vaccination programs, correct and effective use of social media, transparent, and precise management of political processes, and the provision of evidence-based information about the vaccines	High confidence	The study is methodologically complete, with an in-depth approach and relevant theme. The study does not present methodological limitations. The design is adequate, participants' selection is clear, and data collection and analysis follow best practices. The study tool is also suitable for the propose. The method directly impacts the findings. The study is coherent since the findings reflect the COVID-19 vaccination phenomenon, with no ambiguity in the data. The study is rich in detail and the sample is suitable. The study sample is nationwide. Although the search lasted 13 days, the findings were well conducted.
Poon et al., 2021	Recommending COVID-19 Vaccines to Patients: Practice and Concerns of Frontline Family Doctors	Cross-sectional	A total of 312 family doctors responded (17.6% response rate). The proportion of doctors who had received COVID-19 vaccines was 90.1%. The proportion of doctors who would recommend vaccination of all patients without contraindications was 64.4%. The proportion of doctors who would proactively discuss COVID-19 vaccines with patients was 52.9%. Multivariate logistic regression showed that doctors' COVID-19 vaccination status was the strongest predictor of family doctors making a recommendation to patients. Longer duration of medical practice, willingness to initiate the relevant discussion with patients, and less worry about vaccine side effects in patients with chronic illnesses were the other factors associated with making a COVID-19 vaccination recommendation. Family doctors should be encouraged to get vaccinated themselves and initiate discussions about COVID-19 vaccines with patients. Vaccine safety data on patients with chronic illnesses, training, and guidelines for junior doctors may facilitate COVID-19 vaccination recommendations by family doctors.	High confidence	The study approaches the value of family physicians’ recommendations and vaccination results in the target population. The design is a cross-sectional online anonymous survey. The study was developed in the second year of the COVID-19 pandemic. Participants were members and fellows of the Hong Kong College of Family Physicians, the sole governing body for the professional training of family medicine specialists in HK. The setting and family physicians are relevant in the second pandemic year for reaching the target population. The tools were suitable for the study design. Data are deeply explained. The findings are clear and coherent with the target phenomenon, as are the outcome data.
Turbat et al., 2022	Attitudes towards Mandatory Occupational Vaccination and Intention to Get COVID-19 Vaccine during the First Pandemic Wave among Mongolian Healthcare Workers: A Cross-Sectional Survey	Cross-sectional	While only 39.9% of HCWs were aware of recommended occupational vaccinations, they strongly agreed with mandatory occupational vaccination for HCWs (93.7%). The agreement rate was significantly higher than their attitude toward general vaccination (93.7% vs. 77.8%). HCW’s willingness to get the COVID-19 vaccine was high (67.2%). HCWs aged 26-35 years who worked in tertiary hospitals were less willing to get the COVID-19 vaccine (50%). Participants with lower confidence in the efficacy of the COVID-19 vaccine and less positive attitudes toward general vaccination were less likely to get the COVID-19 vaccine. Agreement to mandatory occupational vaccination was higher in Mongolia than in other countries. Intention to get the COVID-19 vaccine was high and associated with confidence in the vaccine´s effectiveness.	Moderate confidence	The design was a cross-sectional study based on an online survey with a convenience sample. A total of 1,576 HCWs viewed the questionnaire, but only 238 responded, showing a low response rate. The study design is a self-reported survey. The survey only approaches WHO and Ministry of Health recommendations on occupational vaccines for measles, polio, rubella, pertussis, influenza, BCG, hepatitis B, varicella, diphtheria, meningococcal meningitis, tuberculosis, and tetanus. There was no question on mandatory COVID-19vaccination. The findings on intent to be vaccinated were consistent with the data and COVID- 19 phenomenon. The data are sufficiently detailed for assessment purposes. It is not clear whether the sample represents the country's entire reality. A subset is available as a population.
Toth-Manikowski et al., 2022	COVID-19 vaccination hesitancy among health care workers, communication, and policy-making	Cross-sectional	In 1,974 completed responses, 85% of HCWs received or anticipated receiving COVID-19 vaccination. Multivariate logistic regression found HCWs were less likely to receive COVID-19 vaccination if they were Black, Republican, or allergic to any vaccine component and more likely to receive it if they believed people close to them thought it was important for them to receive the vaccine. A sizable number remained vaccine-hesitant 1 year into the COVID-19 pandemic. As HCWs are positively influenced by colleagues who believe in COVID-19 vaccination, the development of improved communication across HCW departments and roles may improve vaccination rates.	High Confidence	The study asks HCWs about being vaccinated and mandatory vaccination. There are recommendations to improve HCW vaccination and professional skills. The COVID-19 Vaccine Attitude Scale was adapted from a questionnaire previously developed to measure behavioral determinants of vaccine uptake among healthcare workers during the H1N1 influenza pandemic. The predictive variables used in the multivariate regression analysis are complete and consistent with the findings. The qualitative and quantitative data are detailed and appropriate for the method. The study is relevant, coherent, and adequate, and has no methodological limitations.
Giannitrapani et al., 2022	Promising Strategies to Support COVID-19 Vaccination of Healthcare Personnel: Qualitative Insights from the VHA National Implementation	Interviews	Participants were 22 physicians, 17 nurse practitioners and physician assistants, and 4 registered nurses, from 29 of VHA medical centers throughout the USA. Specifically, the themes included the following: (1) use interdisciplinary task forces to leverage diverse skillsets for vaccine implementation; (2) create detailed processes, addressing time trade-offs for personnel involved in vaccine clinics, designating process/authority to shift personnel where needed, and proactively involving leaders to support resource allocation/alignment; (3) expect and accommodate vaccine buy-in occurring over time: prepare for some HCP's slow buy-in, align buy-in facilitation with identities and motivation, and encourage word-of-mouth and hyper-local testimonials; (4) overcome misinformation with trustworthy communication (5) use existing and newly developed communication channels to foster shared learning across teams and sites.	High confidence	The method is explained in clear detail. There are no limitations to the methodology. The data are consistent with the phenomenon and the findings. The issue, participants, and findings are relevant and representative. The study is useful for policymakers to improve the health system’s response through COVID-19 vaccination.
Carpenter et al., 2022l	Rural community pharmacists’ ability and interest in administering COVID-19 vaccines in the Southern United States	Cross-sectional	69 of 106 pharmacists completed the survey (response rate = 65%). Approximately half of the pharmacists were ready (52%) or actively taking steps (39%) to provide COVID-19 vaccines in the next 6 months. Pharmacies had a median of 2 staff members who were authorized to administer COVID-19 vaccines. Almost half (46%) estimated they could administer more than 30 doses of vaccine per day. Most pharmacies could store vaccines at standard refrigeration (90%) and freezing (83%) levels needed for thawed and premixed vaccines, respectively. Most pharmacists planned to access COVID-19 vaccines through an agreement with a state or local public health entity (48%) or by ordering through group purchasing organizations (46%). Only 23% of pharmacists had received any vaccine training, and only 48% were highly motivated to receive the vaccine themselves.	High Confidence	The method is explained in clear detail. Participants´ responses may have been biased by the $25 stipend. The authors discuss the inclusion of pharmacists in vaccination campaigns. The data are coherent, and the findings reflect the target phenomenon. The data are consistent with the phenomenon and findings. The issue, participants, and findings are relevant and representative.
Harrison et al., 2021	“Somebody Like Me”: Understanding COVID-19 Vaccine Hesitancy among Staff in Skilled Nursing Facilities	Focus group	The findings indicated that some Skill Nursing Facilities’ staff were hesitant to receive the COVID-19 vaccine. Reasons for this hesitancy included beliefs that the vaccine was developed too quickly and without sufficient testing; personal fears about preexisting medical conditions, and more general distrust of the government. Nursing' staff indicated that seeing people like themselves receive the vaccination was more important than seeing public figures. The study cited vaccination effort as a social enterprise and the need to develop long-term care provider-academic-community partnerships in response to COVID-19 and expectation of future pandemics.	Low confidence	Focus group data were analyzed using a phenomenological approach featuring open-ended questions to understand staff experiences with COVID-19 testing and vaccination. The sample size (n =58) is small relative to the 4.5 million healthcare workers in the USA. The authors reflect superficially on the findings. The analysis is not clear or adequately discussed. The method is not able to be replicated to strengthen the study´s impact. Some findings are useful for organizing media campaign policies. The discussion is lost in the demographic analysis, with racial issues revealing insufficient selection of participants. Staff preference to see local community members and people like themselves be vaccinated to improve their confidence is superficial in a discussion about vaccine acceptance during a pandemic. The interview asked about participants' acceptance in three aspects: vaccine availability, reasons for refusing the vaccine, and a remote possibility of a changed scenario. Quantitative and qualitative data are not adequate. The setting was consistent with the objectives. The results are superficially described and fail to explain the context.
Kim et al., 2021	Effect of a hospital-wide campaign on COVID-19 vaccination uptake among healthcare workers in the context of raised concerns for life-threatening side effects	Cross-sectional	A tailored intervention strategy based on a survey can improve COVID-19 vaccination uptake. Of 1,171 HCWs who had received the first dose of the vaccine, 71.5% completed the online survey, of whom 3.7% refused to take the second dose and 22.3% showed hesitancy. Hesitancy to receive a second dose was significantly associated with age under 30 years and was less common among those who trusted the effectiveness and safety of the vaccine. Among HCWs who received the first dose, 96.2% completed vaccination with the second dose. Of those who answered the questionnaire and were asked about the timing of their decision to receive the second dose, 57.1% reported that they were motivated by the hospital-wide campaign.	High Confidence	The method is explained in clear detail. The survey was applied in two phases, addressing the acceptance of both the first and second doses. The measures applied are described well, with in-depth discussion of the approaches. There are no limitations to the methodology. The study is coherent, and the data are consistent with the phenomenon and findings. The qualitative and quantitative data are adequate. Detailed tables and figures contribute to the explanation. The topic, participants, and findings are relevant and representative. The study is useful for vaccine uptake by the HCW when planning vaccination campaigns.
Qunaibi et al.,	Hesitancy of Arab Healthcare Workers towards COVID-19 Vaccination: A Large-Scale Multinational Study	Cross-sectional	This large-scale multinational post-vaccine-availability study on COVID-19 vaccine hesitancy among HCWs revealed high rates of hesitancy among Arab-speaking HCWs. Unless addressed properly, this hesitancy can impede the efforts for achieving widespread vaccination. The survey recruited 5,708 participants from 21 Arab countries (87.5%) and 54 other countries (12.5%). The analysis showed a significant rate of vaccine hesitancy among HCWs residing in and outside of Arab countries (25.8% and 32.8%, respectively). The highest rates of hesitancy were among participants from Egypt, Morocco, Tunisia, and Algeria. The most widely cited reasons for hesitancy were concerns about side effects, distrust of expedited vaccine production, and healthcare policies. Factors associated with higher hesitancy included age 30-59 years, previous or current suspected or confirmed COVID-19, female gender, not knowing the vaccine type authorized in the respective country, and not regularly receiving the influenza vaccine. Unless addressed properly, this hesitancy can impede efforts for achieving widespread vaccination and collective immunity.	High confidence	A cross-sectional study was conducted through an online survey. There were no methodological limitations. The survey uses an adequate tool. Participants´ selection, settings, and method are described in detail. The analysis is based on all the collected data. The outcomes have an important impact, and the method can be applied in futures studies. The findings are discussed and reflect the target phenomenon. Qualitative and quantitative data are presented in detail to understand the phenomenon described in the findings. The survey was developed in 75 countries with Arab-speaking HCWs, totaling 5,708 respondents. The findings suggest the improvement of communication with HCWs, listening to their concerns and suggestions, with the development of a transparent, evidence-based healthcare policy, and the incorporation of representative healthcare workers in healthcare decision-making.
Ashok et al., 2021	High COVID-19 Vaccine Hesitancy Among Healthcare Workers: Should Such a Trend Require Closer Attention by Policymakers?	Cross-sectional	The study showed a high rate of vaccine hesitancy (delay /refusal) among HCWs. Among 264 respondents, 40.2% of HCWs would receive the COVID-19 vaccine if available and 32.2% were willing to take the vaccine after observing adverse effects in others. Factors significantly associated with vaccine acceptance were infected members in social networks, COVID-19 knowledge, the safety of vaccines, and not having received a flu vaccine in the previous year. The main reasons for delay/refusal to vaccinate were rapid vaccine development and compromised quality (43.7%) and lack of trusted information regarding COVID-19 (41.3%).	Low confidence	The study is limited to individuals with internet access, which is a major limiation. The sample is also small, with fewer respondents and unequal distribution of resptondents across the country (India). The target phenomenon and findings are relevant, but the data need to be more consistent because the sample is too small. The data are inadequate because the sample includes only physicians, mainly pediatricians. The sample size was too limited to obtain significant predictors of vaccination in multinomial regression. However, the study´s implementation and topic of interest are relevant. The study is intended to be national, but the country´s population appears to be underrepresented. The subset of the population is not representative.
Pitini et al., 2021	How Public Health Professionals View Mandatory Vaccination in Italy—A Cross-Sectional Survey	Cross-sectional	Among the 1,044 respondents (77% response rate), a large majority favored the Italian mandatory vaccination law (91%) and were against its repeal (74%). According to respondents, maintaining high vaccination coverage without the need for mandatory vaccination would be preferable, and thus efforts to promote vaccine confidence and proactive vaccine uptake are still needed.	Low Confidence	The methodology has some limitations. The impact of the pandemic is more severe than known diseases. So, the comparison is unbalanced, and the contribution is weak for the COVID-19 vaccination mandatory policy. The target phenomenon and findings should be coherent with the COVID-19 context. Qualitative and quantitative data can help understand the main measures for mandatory vaccination for known diseases. The study has no relevance for the setting or target topic. It also was conducted according to a law published before the pandemic.
Riccò et al., 2021	Mandate or Not Mandate: Knowledge, Attitudes, and Practices of Italian Occupational Physicians towards SARS-CoV-2 Immunization at the Beginning of Vaccination Campaign	Cross-sectional	Occupational physicians exhibited wide acceptance of SARS-CoV-2/COVID-19 vaccination, and the majority endorsed required vaccination for HCWs, which may help improve vaccination rates in occupational settings. A high perception of SARS-CoV-2 risk was reported in around 80% of participants (79.5% regarding its occurrence, 81.9% regarding its potential severity). Vaccination was endorsed by 90.4% of respondents. Endorsement of required vaccination was reported by 60.2% of respondents.	High confidence	The study is coherent, and the method is clear, complete, and well-designed. Practice by occupational physicians is closely related to the target phenomenon. The authors offer reflections on the relationship between the objectives and findings. Thet study tools were adequate for this type of research. The sample was representative and can contribute to work by other vaccination teams. Regarding adequacy, the issue of mandatory versus nonmandatory vaccination requires further investigation to help health system managers make decisions. The study is relevant because the participants can become critical players in encouraging vaccine acceptance. In addition, although an online tool was used, the authors performed an excellent study with a complete analysis. After the survey, the results showed that occupational physicians showed wide acceptance of COVID-19 vaccination, and the majority endorsed mandatory vaccination for HCWs, which may help improve vaccination rates in occupational settings.
Baumer-Mouradian et al., 2021	Urgent COVID-19 Vaccination of Healthcare Workers via a Quality Improvement Initiative	Cross-sectional	The article describes the development and implementation of a successful COVID-19 employee and community vaccination program. 3,921 healthcare workers completed the survey, and 73% reported intent to receive the COVID-19 vaccine immediately or later. After 57 clinic days, 83% (n = 5,231) of healthcare workers were vaccinated, and 99% completed the two-dose series. Vaccine waste was minimal at 0.1%.	Moderate confidence	The article highlights the unique differences between large-scale COVID-19 vaccination programs and established influenza vaccine campaigns. The authors failed to describe the method. They explain that a “vaccine team,” including hospital leadership, employee health and wellness, nursing and pharmacy leadership, and a provider was formed to develop and implement a COVID-19 vaccination program. On the other hand, a survey was cited in the outcomes, which was not mentioned in the methodology. The study describes developing and implementing a successful COVID-19 employee and community vaccination program. The phenomenon and findings are coherent, and the qualitative and quantitative data are explained adequately. The children’s health system is a freestanding, not-for-profit pediatric academic center and comprises a tertiary care hospital and primary and specialty pediatric care services. Therefore, the setting and population are relevant to the topic. The program was successful.
Mei Li et al., 2021	Health care workers’ (s) attitudes and related factors towards COVID-19 vaccination: a rapid systematic review	Systematic review	Vaccine acceptance varied widely and ranged from 27.7% to 77.3%. HCWs had positive attitudes towards future COVID-19 vaccines, while vaccine hesitancy was still common. Demographic variables such as male gender, older age, and medical profession were positive predictive factors. Women and nurses showed more vaccine hesitancy. Previous influenza vaccination and self- perceived risk were facilitators. Concerns for safety, efficacy, and effectiveness and distrust of the government were barriers. Influences of direct (COVID-19) patient care towards vaccination intention were less conclusive. Tailored communication strategies were needed to increase the uptake rate of COVID-19 vaccines among HCWs. More importantly, more data and information on the safety and efficacy of vaccines should be provided with transparency	High confidence	There are minor methodological limitations to the review findings. This rapid systematic review has limitations since there was no search in the grey literature and only two languages were included in the criteria. The study is coherent regarding the target phenomenon, findings, and data. The study reports adequate data. The "herd immunity" concept is used, which was commonplace at the beginning of the COVID-19 pandemic. The study is relevant because the USA was an important country for assessing HCWs' willingness to be vaccinated. The results showed that HCWs had positive attitudes towards future COVID-19 vaccines, while vaccine hesitancy was still common. Demographic variables such as male gender, older age, and the medical profession were positive predictive factors. Women and nurses showed more vaccine hesitancy. Previous influenza vaccination and self- perceived risk were facilitators. Concerns for safety, efficacy, and effectiveness and distrust of the government were barriers. The influence on vaccination intention of having performed frontline COVID-19 patient care was less conclusive. The authors suggest a tailored communication strategy to increase COVID-19 vaccine uptake among HCWs.

HCW OUTCOMES REGARDING TO PHENOMENA OF INTEREST

HCW requirements and skills for target population coverage

Most of the articles that aimed to identify HCW´s skills for increasing vaccination rates were based on the search for factors associated with vaccine hesitancy. Thus, most reports suggest behaviors that help achieve vaccination coverage targets. For health systems, failure to increase vaccine uptake may be a tragic public health legacy of the COVID-19 pandemic (17). A survey that aimed to explore non-vaccination found the influence of other behaviors, mistrust of proper vaccine storage, and reliance on social media, newspapers, and television as factors related to low vaccination adherence (7). An extensive survey in the United States found that perceived susceptibility to side effects was a negative predictor of COVID-19 vaccination intention. Another interesting finding was that vaccine-related knowledge indirectly and positively affected vaccination intention by decreasing perceived susceptibility. Physician-patient communication also strengthened the negative effect of vaccine knowledge on perceived susceptibility and severity (18) .

Communication is an important skill. Physicians can initiate conversations on COVID-19 vaccination with their patients either at the in-person point of care or via online communication platforms (18). Vaccine hesitancy can be addressed by careful attention to the application of vaccination programs, correct and effective use of social media, transparent and precise management of policy processes, and the provision of evidence-based information on vaccines (19).

The health and care workforce displayed positive attitudes towards future COVID-19 vaccines, while vaccine hesitancy was still common. Demographic variables such as male gender, older age, and the medical profession were positive predictive factors. Women and nurses showed more vaccine hesitancy. Previous influenza vaccination and self-perceived risk were facilitators. Concerns with vaccine´s safety, efficacy, and effectiveness and distrust of the government were barriers (9).

Policy, management and regulation for vaccination

The searches in this review identified few studies on national policies, regulations, and management of the pandemic. Most of the studies discussed mandatory COVID-19 vaccination (and the legality of this measure) and vaccine acceptance by HCW. Most literature preferred maintaining high coverage without making vaccination mandatory. Thus, efforts to promote vaccine confidence and proactive vaccine uptake are still needed (20). Meanwhile, the rate of agreement on mandatory occupational vaccination was higher in Mongolia than in other countries. Mongolian HCW’s intention to get the COVID-19 vaccine was high and associated with confidence in the vaccine´s effectiveness (21) . Future research may further assist decision-making on this sensitive topic.

Barriers and mechanisms to improve vaccination teams´ performance and productivity

Early in the COVID-19 vaccine rollout in the Southern United States, most rural pharmacies were interested in and preparing to administer COVID-19 vaccines. In a cross-sectional survey, few rural pharmacists had received COVID-19 training, and many expressed some hesitancy to receive the vaccine themselves. The number of vaccines that pharmacists could administer varied according to the pharmacy´s and pharmacist´s characteristics (22). Participants were asked about the timing of their decision to receive the second dose, and 57.1% reported that they were motivated by a hospital-wide campaign. A tailored intervention strategy based on a survey can improve COVID-19 vaccination uptake (23).

In another survey, occupational physicians displayed wide acceptance of SARS-CoV-2 vaccines, and the majority endorsed mandatory vaccination for HCWs, which can help improve vaccination rates in occupational settings (8). Tailored communication strategies are needed to increase the rates of COVID-19 vaccine uptake in the HCW. More importantly, more data and information on the safety and efficacy of vaccines should be provided with transparency (24). No articles were found directly related to vaccination teams´ productivity, mechanisms for improvement, and performance assessment.

Barriers and enablers of HCW vaccination coverage

According to a qualitative study, nurses believed that the vaccine had been developed too quickly. Without sufficient testing, personal fears about preexisting medical conditions and more general distrust of the government were critical factors for low vaccination (25). Another survey showed that vaccination created negative emotions among some HCW. The opinions of the health and care workforce about the COVID-19 vaccines were affected by the negative emotions and burnout they experienced during the pandemic. The vaccination process was impacted by contraindications and uncertainty about the duration of the protection. The trade-off between benefits and harms from vaccines and vaccine myths and prejudices were also significant concerns. HCW expressed the need to establish trust in vaccination. They suggested that different vaccine options should be offered, appointment and notification system for vaccination should be improved, evidence-based information on vaccines should be provided, and a safe environment should be created (19).

An extensive survey of Arab-speaking HCWs found high vaccine hesitancy rates. This hesitancy can impede efforts to achieve widespread vaccination and collective immunity (6). Another study with the HCW found that hesitancy to receive a second dose was significantly associated with age under 30 years, and that concerns about the vaccine were less common among those who trusted the vaccine´s effectiveness and safety. Among those who had received the first dose, 96.2% completed the vaccination with the second dose (26).

Participants in a cross-sectional study in Mongolia showed lower confidence in the efficacy of the COVID-19 vaccine and less favorable attitudes toward general vaccination. They were less likely to get the COVID-19 vaccine (21) . The fact that they were positively influenced by colleagues who believed in COVID-19 vaccination suggests that improved communication between HCW departments and roles can improve vaccination rates (27).

The main reasons for delaying or refusing vaccination according to another study were rapid vaccine development and compromised quality (43.7%) and lack of trusted information regarding COVID-19 (41.3%) (21). To mitigate these barriers, awareness-raising campaigns should focus on enhancing perception of the vaccine´s benefits by debunking misconceptions and emphasizing COVID-19´s severity.

In a survey of family physicians, the authors concluded that HCWs should be encouraged to be vaccinated themselves and initiate discussions with patients about COVID-19 vaccines. Vaccine safety data on patients with chronic illnesses, training, and guidelines for junior physicians can facilitate family physicians´ recommendation of COVID-19 vaccination (28) .

GENERAL/TARGET POPULATION OUTCOMES REGARDING TO PHENOMENA OF INTEREST

Vaccinating the population to contain the pandemic is a priority that should be possible for all countries. Various obstacles have hindered vaccination teams´ performance. Knowing the reasons for such obstacles may help solve the problem.

A qualitative study described a successful planning experience with vaccination in a primary care setting. Hesitant patients were submitted to an organizational intervention, after which the acceptance rate increased (28). More countries need to develop such interventions

Government agencies should actively emphasize the effectiveness and importance of vaccination while publicly addressing concerns about vaccine safety. Health system initiatives should also enhance knowledge about COVID-19 vaccines through various media channels (29).

A systematic review of access to vaccination by migrants and minorities in many countries highlighted concerns about migration and health and care systems(30). Low confidence in COVID-19 vaccines among Black populations, driven by mistrust and safety concerns, led to high vaccine hesitancy according to one systematic review. Vaccine hesitancy poses a significant barrier to COVID-19 vaccine uptake in this ethnic minority. For migrants, convenience factors such as language barriers, fear of deportation, and limited physical access have reduced access to COVID-19 vaccines (30).

Public health experts should also attenuate the perceived barriers by providing vaccines and allaying people's concerns about their storage, effectiveness, and adverse events (9). Vaccine hesitancy can be addressed by careful attention to the application of vaccination programs, correct and effective use of social media, transparent and precise management of policy processes, and the provision of evidence-based information about vaccines (19).

In the United Kingdom, to improve trust and confidence in the country´s COVID-19 vaccination program requires clarity on what is known and not known about the vaccines and transparency around the evidence base supporting government decisions on vaccine rollout. An effort is also needed to dispel the spread of online vaccine-related misinformation and to address specific concerns, particularly among Black, Asian, and minority ethnic (BAME) and junior-level HCWs (30). With effective vaccine promotion campaigns, policymakers should increase public awareness and secure timely and affordable vaccines for the general population (31).

Building trust, reducing physical barriers, and improving communication and transparency about vaccine development through HCW and religious and community leaders can improve access and facilitate the uptake of COVID-19 vaccines among ethnic minorities and migrant communities (30) (23). The best and most successful policy choices about the pandemic should be shared by countries for COVID-19 and other diseases with similar characteristics.

We reviewed the main reasons for COVID-19 vaccination acceptance and refusal in the HCW and the general population, providing useful elements for advancing public policies to improve vaccination performance. Reasons for refusal to vaccinate were similar between the HCW and the general population.

However, there were few multicenter studies and we excluded commentaries and opinion articles. Most of the study designs were cross-sectional and qualitative. The documents and articles published from 2020 to 2022 displayed various problems with reliability. Distrust and refusal by physicians and nurses to be vaccinated is problematic, since the HCW is a model of behavior for the general population. More research is needed to report on campaigns and strategies to improve the productivity of vaccination teams.

More research is also needed on government provisions pertaining to vaccination. The controversy over mandatory and priority vaccination of the HCW and vulnerable groups revealed a context of legal possibilities, but without conclusions as to enforcement in the countries. In other words, few studies addressed the regulation of vaccine campaigns and mandatory vaccination of the HCW and the general population.

We found few studies on policies, regulations, and mechanisms to improve the productivity and performance of vaccination teams. The emphasis was on validating HCW´s perceptions concerning vaccination acceptance versus hesitancy. On this point, the only progress was in understanding the regulatory mechanisms and public policies that countries used to increase COVID-19 vaccination coverage. According to a recent systematic review and meta-analysis (32), reminders via mobile phones on interventions to improve coverage and timeliness of routine childhood vaccination enjoyed wide acceptance, thus providing a technological approach that can be used to increase COVID-19 vaccination in the general population.

Meanwhile, requirements to facilitate HCW’s communication with the population were reported frequently, including confidence in the vaccines´ efficacy and safety, the relevance of clear and transparent communication to counteract fake news, and government positioning based on science and targeted to the vulnerable population. Training for physicians, nurses, and pharmacists to conduct vaccination campaigns can help increase coverage in both urban and rural areas. The main driver for Health care workers to convince the population to be vaccinated is their own belief in the vaccine and their willingness to be vaccinated themselves.

. There were few multicenter studies and numerous opinion articles. This study analised publications from the first two years of pandemic 29 texts met the inclusion and quality criteria (PICo) for data extraction, ten were excluded after the assessment. Most of the 19 study designs were cross-sectional and qualitative. Applying GRADE CERQual tool from 19 studies there was 12 with high confidence, 4 with moderate e 3 with low confidence. The systematic review presented limitations regarding the number and trustworthiness of documents and articles published from 2020 to 2022. The limited numbers of studies make difficult to satisfactorily answer in depth all the review questions. Further assessments with the same search strategies for publications after 2021 are recommended to improve the analysis.

Final remarks: valuable lessons for policies to deal with COVID-19 vaccination and future pandemics

The COVID-19 highlighted that for future pandemics Governments and health system administrators will need guidance to develop and implement policies for vaccine coverage, to communicate transparently with the population to control outbreaks involving new strains, and to ensure that vaccination reaches the world´s entire population. In the beginning of COVID-19 pandemic LIC and MIC suffered a shortage of vaccines and demanded access to vaccination.Vaccines donation was the best solution for covering the population. Gaps in vaccination coverage contribute to the failure of public policies and affect the organization of health and care systems. Poorly organized government policies for mass vaccination have fueled distrust in the population concerning the effectiveness and need for the vaccine to defeat the pandemic.

Mandatory vaccination of the general population should consider factors associated with lower coverage and higher morbimortality, such as male gender, older age, minority ethnicity, refugees/migrant status, institutionalization, and residence in rural areas.

Communication during pandemics needs to be clear, transparent, evidence-based, and published by official government channels to be incorporated and support the development of guidelines for the population.

Collective immunity through vaccination is sometimes delayed during a pandemic to target resources to groups with the highest case-fatality, thus placing pressure on health services. Training in vaccination has been essential for improving vaccine coverage in both urban and rural areas.

Vaccine hesitancy is also a problem among HCW. The most significant reasons for vaccine hesitancy are fears about the vaccine´s safety associated with fast-track vaccine development (perceived as insufficient testing of the vaccines before releasing them for mass vaccination) and doubts about safe storage of the vaccines. HCW´s behavior acts as a model for the population. Refusal by HCW to be vaccinated can negatively impact vaccination coverage in target populations and jeopardize vaccination campaigns.

Tailored communication can increase the uptake rate of vaccines by the HCW. According to a systematic review conducted before COVID-19 (10), pay-for-performance (P4P) can increase vaccination in the population by providing financial incentives to providers to achieve pre-established quality outcomes. Based on the findings, implementing P4P programs can increase vaccination rates. However, LICs with inadequate vaccination also lack the financial resources to implement such strategies.

Global campaigns to support HCW vaccination are crucial for emphasizing the severity of the disease and for counteracting misinformation. Public health experts can minimize barriers to vaccine uptake by providing information about vaccines´ storage, effectiveness, and safety. Gender is potentially important and a neglected aspect in most studies reviewed.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Availability of data and materials

The database of the literature review is available upon request from the authors.

Competing interests

The authors declare that they have no competing interests.

PROSPERO registration number: CRD42022325111

Acknowledgements

Project developed in response to WHO’s call 2021-016_UHC-HWF_WrkforceIntel published by the funder; grant registration number 2021/1175760-0 - Purchase Order 20275943 - Unit Reference HWF/HWP.

Centro de Estudos, Pesquisa e Desenvolvimento Tecnológico em Saúde Colectiva (CEPESC) and Instituto de Medicina at Universidade do Estado do Rio de Janeiro (IMS/UERJ) provided management/administrative support.

Portuguese Fundação para a Ciência e Tecnologia provides funds to Global Health and Tropical Medicine (GHTM), Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa (IHMT/UNL) (GHTM UID/04413/2020).

The authors wish to thank Dr Giorgio Cometto (Health workforce department, World Health Organization, Geneva) for helpful discussions and guidances.

Funding

Project developed in response to WHO’s call 2021-016_UHC-HWF_WrkforceIntel published by the funder; grant registration number 2021/1175760-0 - Purchase Order 20275943 - Unit Reference HWF/HWP. The donors had no role in the conceptualisation, review or approval of this manuscript.

Authors' contributions

APS, APCO, IF, IC, GC, LSM, MRDP and PF designed the systematic literature review. APS, LC and RC defined the search strategies and conducted the database base search, APS and LC assessed studies regarding eligibility and collected data. APS, LC, PF and MRDP produced the first version of the manuscript. All authors read and approved the final manuscript. The authors alone are responsible for the content of this manuscript.

Corresponding author: Alessandra Pereira da Silva

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Kappa values were calculated to measure agreement between two reviewers (APS and LC). The reviewers considered the standard error, level of agreement, and respective 95% confidence intervals (source of instrument: www.vassarstats.net). (13)
Algeria, Bahrain, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, UAE, and Yemen.
Netherlands, United Kingdom, France, Germany, Spain, Sweden, Bosnia and Herzegovina, Italy, Austria, Romania, Republic of Ireland, Switzerland, Cyprus, Ukraine, Denmark, Aruba (Netherlands), Norway, British Virgin Islands (United Kingdom), Greece, Belgium, Hungary, Czech Republic, Poland, Finland, and Luxembourg.
Australia, India, Russia, Ethiopia, Japan, China, Kyrgyzstan, Cayman Islands (United Kingdom), Malaysia, Ecuador, Pakistan, Uzbekistan, Kazakhstan, Bulgaria, Belarus, South Africa, Brunei, Argentina, Georgia, Iran, Guadeloupe (France), South Korea, Chad, Jamaica, the Bahamas, and the Gambia.

AnnexFile.docx

COVID-19 vaccination acceptance and hesitancy in health and care workers and the general population: a systematic review and policy recommendations

Status:

Version 1

Abstract

Figures

Introduction

Methods

Results

Discussion

Final remarks: valuable lessons for policies to deal with COVID-19 vaccination and future pandemics

Declarations

References

Footnotes

Supplementary Files

Status:

Version 1