Mandatory COVID-19 vaccination for healthcare workers: A discussion paper

Distrust, trauma, doubt, and protective reactions to coronavirus disease 2019: cautionary tales and lessons to learn for future pandemics: a case report

BACKGROUND

Vaccine uptake has declined since the coronavirus disease 2019 pandemic began. The pandemic changed people's perception about vaccination due to factors such as increasing mistrust in government, spread of misinformation, fear of side effects, unclear communication, concerns about rushed vaccine development, and opposition to mandates infringing on personal choice. Understanding different perspectives on vaccine decision-making is crucial for informing effective approaches to communicating about vaccines.

CASE PRESENTATION

This study presents three cases with varying attitudes and behaviors about vaccination for coronavirus disease 2019, traditional childhood illnesses, and influenza influenced by different contexts and experiences. The cases span the continuum of vaccine hesitancy and uptake, from distrustful and resistant (Alexis, 56-year-old non-Hispanic White American female), through resentment for mandated uptake of the expedited coronavirus disease 2019 vaccine versus trust of long-standing preventive vaccines (Nia, 51-year-old non-Hispanic Black American female), to accepting and adopting (David, 38-year-old non-Hispanic White American male). These cases have similarities and differences across ten key "themes," including vaccine attitudes; decision-making motivations; prioritizing family's health; influence of past vaccination trauma on decision-making; significance of social support; the importance of information to guide decisions; (dis)trust in news, social media, and politicians; disappointment in humanity; future recommendations including respecting individual autonomy and providing the necessary information for individual decision-making; and openness to future vaccines.

CONCLUSION

The long-term impact of the public health response-including vaccine mandates-and aftermath of stigmatization of people with differing and less socially desirable vaccine beliefs on vaccine uptake and health and medical service engagement remains unknown. By drawing on rich, nuanced information collected from individuals at a time of intense national dialogue around vaccines, these three case studies offer unique and novel insights into how the dialogue around vaccine uptake should evolve to meet the needs of different people. These findings have implications for broadly promoting public health engagement by hearing varied experiences and tailoring approaches to reach diverse groups of individuals. Findings from these cases provide insights and recommendations for tailoring future pandemic-related responses to audiences with similar beliefs and experiences as those presented in these cases.

Profiling vaccine hesitancy in nursing to tailor public healthcare policies: A cross-sectional international study

INTRODUCTION

Vaccine hesitancy is a complex issue of global concern. As nurses play a vital role in delivering patient care and shaping public opinions on vaccines, interventions to address vaccine hesitancy in nursing are imperative. As such, identifying profiles of characteristics and attitudes contributing to hesitancy may help identify specific areas of focus to target tailored global vaccination uptake campaigns. The purpose of this study was to profile the characteristics and attitudes contributing to hesitancy toward COVID-19 and Influenza vaccines in the nursing community.

DESIGN

This multisite, cross-sectional study recruited 1967 registered nurses and 1230 nursing students from the United Kingdom, Finland, and Italy between March and September 2023.

METHODS

Data collection involved an online survey adopting the Vaccination Attitudes Examination (VAX) Scale, the Bergen Social Media Addiction Scale, and questions pertaining to sociodemographic and occupational characteristics. A k-means cluster analysis was used to identify various clusters of hesitancy based on the VAX Scale. One-way ANOVA and chi-square tests were used to identify significant differences in sociodemographic characteristics, occupational factors, vaccination attitudes, and social media usage between the clusters.

RESULTS

Three distinct clusters were identified. Profile A showed high vaccine confidence, profile B displayed slight hesitancy, and profile C reported high levels of hesitancy. In profile C, higher levels of vaccine hesitancy were identified in younger, less experienced nurses with lower educational attainment. While older nurses with higher educational attainment, who were in senior roles, were more vaccine-confident and had a consistent history of accepting the Influenza and COVID-19 vaccinations (profile A). The study found Italian nurses highly hesitant (profile C), British nurses highly confident (profile A), and Finnish nurses evenly distributed between confident, slightly hesitant, and highly hesitant (profiles A, B, and C, respectively). In addition, more frequent usage of Instagram and TikTok was associated with vaccine hesitancy (profiles B and C), and LinkedIn and X were more common among vaccine-confident individuals (profile A).

CONCLUSIONS

This study has identified specific sociodemographic and occupational factors that are related to vaccine hesitancy in an international sample of nurses. Additionally, attitudes contributing to hesitancy were identified, with worries about unforeseen future effects of the vaccine being identified as a critical attitude that may undermine confidence and increase hesitancy in nursing. This study also sheds light on the influence that social media platforms have on vaccine hesitancy and, as such, indicates which platforms are effective to disseminate vaccination campaigns to global nursing communities.

CLINICAL RELEVANCE

Global vaccination campaigns should focus on specific profiles and clusters to promote vaccination in the international nursing community. Empowering nurses early in their careers will help to instill positive vaccination behaviors, ensuring a sustained uptake of vaccinations throughout the individual's career and beyond, with an impact on promoting vaccination at the public health level as well.

Barriers and enhancers to COVID-19 vaccination among healthcare workers in Zimbabwe

Background

Coronavirus disease 2019 (COVID-19) vaccination is crucial for healthcare workers (HCWs). Understanding their vaccine uptake and perceptions is vital to promote acceptance.

Aim

This study assessed COVID-19 vaccine uptake, associated factors and HCW willingness to recommend vaccination in Zimbabwe.

Setting

The study was conducted through a cross-sectional survey involving 200 HCWs in seven central healthcare facilities from May 2023 to June 2023.

Methods

Data on demographics, vaccination status, knowledge, attitudes and trust in information sources were collected. Descriptive statistics and modified Poisson regression identified factors associated with vaccine uptake.

Results

Of the respondents (female: 68%, median age [interquartile range {IQR}: 34]; [28-43] years), 94% (188/200) had received at least one dose of the COVID-19 vaccine, with 49.5%, 41% and 3.5% having been fully vaccinated, received a booster and partially vaccinated, respectively. Also, 74% of the HCWs would recommend the COVID-19 vaccines to their patients. Out of the total, 15% of HCWs identified that vaccine safety was their major barrier to getting vaccinated. The vaccination rate among nurses and midwives was 9.6% (prevalence ratio [PR]: 0.904; 95% confidence interval [CI]: 0.833, 0.981) lower when compared to physicians. The study also identified that the booster vaccination rate was higher in older HCWs (PR: 1.02; 95% CI: 1.01, 1.03).

Conclusion

High COVID-19 vaccine uptake was observed among HCWs in Zimbabwe. However, concerns about vaccine safety persist. Targeted interventions addressing these concerns are needed to maximise vaccine acceptance in this key population.

Contribution

This study reveals specific reasons for vaccine hesitancy among HCWs in Zimbabwe.

Impact of COVID-19 pandemic on vaccine hesitancy and sentiment changes: A survey of healthcare workers in 12 countries

OBJECTIVES

Healthcare workers (HCWs) are a trusted source of vaccine-related information for patients and communities, but they can show hesitancy or reluctance towards vaccinations. The objective of our study was to investigate HCWs' sentiment and hesitancy towards vaccination, focusing on COVID-19 and influenza vaccination.

STUDY DESIGN

A global cross-sectional study spanning four continents.

METHODS

Utilizing a web-based survey, we gathered responses from 7793 HCWs across twelve countries. We used Latent Class Analysis models to build response profiles for respondents. We employed multilevel multivariable logistic regression models to assess the impact of individual determinants and country contextual effects on change in vaccine sentiment (ChVS) and COVID-19 vaccine hesitancy (CoVH).

RESULTS

HCWs exhibited high agreement on the safety, effectiveness, and usefulness of vaccines. However, 21% reported strong or moderate CoVH. Country contextual effects significantly influenced ChVS and CoVH, with variations observed across nations, accounting for 6% of global variance in both ChVS and CoVH. Individual factors such as educational level, fear of contracting COVID-19, knowledge of COVID 19 vaccines, CoVH, influenza vaccination behaviour and general confidence in vaccines significantly influenced ChVS. CoVH was related to profession, influenza vaccination behaviour, fear of COVID-19 and main information sources.

CONCLUSIONS

Individual factors played a major role in determining change in vaccine sentiment and COVID-19 vaccine hesitancy, but they can be modulated by other contextual elements at the country level. There is a need for tailored, nation-specific strategies to address vaccine hesitancy and enhance vaccine confidence among HCWs.

Insight into pharmacy students' perspectives on mandatory COVID-19 vaccines in schools and healthcare settings

Background

The COVID-19 pandemic has had an extreme global impact, transforming our daily lives, educational systems, and healthcare systems. Healthcare workers' views on mandatory vaccination and experience with vaccines may play a pivotal role in vaccination rates and public health policy.

Objectives

The purpose of this study is to uncover the perspectives of pharmacy students, at Xavier University of Louisiana, concerning COVID-19 vaccination mandates in educational institutions and healthcare environments, specifically the ethical, legal, and logistical dimensions. Furthermore, it will also assess the varying perceptions of vaccine safety and its impact on herd immunity while analyzing demographic characteristics.

Design

A questionnaire survey.

Methods

This cross-sectional study was conducted among students at Xavier University of Louisiana College of Pharmacy. Data were collected from the students using an online, anonymous questionnaire system named QualtricsXM. The survey was distributed to all 291 XULACOP students through email, text message, and GroupMe as a web link or QR code from August 25th to August 31st, 2023. Demographic data collected in the survey included age range, gender, and race/ethnicity. The 16-question survey assessed the students' understanding, opinions, and experiences regarding COVID-19 vaccines and mandates.

Results

The study sample included 151 students, reflecting a 52% response rate. Approximately, half of the study respondents believe the vaccine should be mandatory for the public, which was associated with opinions about students believing COVID-19 vaccines should be mandatory for school admissions were seven times more likely (OR = 7.33) and students believing mandatory vaccination infringes on personal freedom were 26% less likely (OR = 0.26) to support mandatory COVID-19 vaccines for the public(p = 0.000). When analyzing demographic characteristics, there was a significant difference in outcome between Black and non-Black students in their belief about mandatory vaccination for herd immunity (p = 0.016).

Conclusion

The findings of this study indicate that half of the students support making the vaccine mandatory for the public. However, significant concerns about personal freedom and individual rights were expressed by those who opposed this view. Varying pharmacy student opinions among demographic groups on vaccine mandates and understanding the factors influencing these differences can offer valuable insights into public health policy.

A Systematic Review of the Attitudes, Beliefs, and Acceptance of the COVID-19 Vaccine in the Western and Eastern Hemispheres

The availability of an effective vaccine does not equate to its use; its effectiveness primarily depends on vaccine acceptance by the targeted population. Despite the rapid development and widespread access to the COVID-19 vaccine, herd immunity is yet to be achieved, with vaccine hesitancy as a major barrier. This study sought to systematically assess the beliefs, attitudes, and acceptance towards COVID-19 vaccines, including factors contributing to vaccination hesitancy in the Eastern and Western Hemispheres. A comprehensive search of articles was conducted through Scopus, PubMed, Embase, CINAHL, Cochrane CENTRAL, and Web of Science databases for studies published from inception to May 2023 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our search yielded 1154, of which 21 were eligible for inclusion. The rate of willingness or intention to vaccinate varied with the geographic region, from 12% in the United States to 93.9% in China. Four studies from the Western region and two from the Eastern region reported a low acceptance rate (defined as <50%): United States (12%), Spain (48.3%), Switzerland (38.6%), Europe (multi-national, 31%), Nepal (38.3%), and Oman (43%). Overall, vaccine acceptance was low to moderate in the general population and healthcare workers (HCWs) in both Eastern and Western Hemispheres except for China which reported high acceptance (defined as >75%) among the general population and HCWs. Demographic characteristics (female, younger age, and higher education) and non-demographic factors (knowledge about the COVID-19 vaccine and its development, history of influenza vaccination, perceived susceptibility or severity of infection, and the belief that vaccines are effective in controlling the pandemic) were associated with high acceptance rates or intentions to take the COVID-19 vaccine. On the other hand, mistrust of the vaccine, its safety and effectiveness, disinformation or poor awareness of the vaccine, side effect concerns, belief in natural immunity, previous adverse experience with the vaccines, and distrust in the information sources about the COVID-19 pandemic were associated with vaccination hesitancy. For better acceptance, COVID-19 vaccination campaign strategies should be modeled based on regional political, economic, and social contexts.

Scarcity of medical ethics research in allergy and immunology: A review and call to action

Medical ethics is relevant to the clinical practice of allergy and immunology regardless of the type of patient, disease state, or practice setting. When engaging in clinical care, performing research, or enacting policies on the accessibility and distribution of healthcare resources, physicians regularly make and justify decisions using the fundamental principles of medical ethics. Thus, knowledge of these principles is paramount for allergists/immunologists. To date, there has been a shortage of medical ethics research in allergy and immunology. This review describes this scarcity, highlights publication trends over time, and advocates for additional support for research and training in medical ethics with a focus on topics germane to the practice of allergy and immunology.

Ethical decision-making: exploring the four main principles in nursing

Nurses are regularly confronted with moral questions and ethical dilemmas in their practice, for example where a patient's decisions about their treatment conflict with the nurse's own views. While the standards contained in the Nursing and Midwifery Council The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates provide nurses with an overarching framework to guide practice, it is important that nurses understand the four main principles that underpin ethical care - autonomy, beneficence, non-maleficence and justice. This article examines these four principles and how they relate to nurses' ethical decision-making. The author also explores how nurses' ethics were tested by the coronavirus disease 2019 (COVID-19) pandemic. Having an awareness of ethical decision-making can enhance nurses' practice by providing them with a theoretical framework for treating patients with dignity and respect.

Is resistance to Covid-19 vaccination a "problem"? A critical policy inquiry of vaccine mandates for healthcare workers

As the COVID-19 global vaccination campaign was launched in December of 2020, vaccination became mandatory for many healthcare workers (HCWs) worldwide. Large minorities resisted the policy, and the responses of authorities to this resistance led to damaged professional reputations, job losses, and suspension or termination of practice licenses. The joint effect of dismissals, early retirements, career changes, and vaccine injuries disabling some compliant HCWs from adequate performance has exacerbated existing crises within health systems. Nevertheless, leading health authorities have maintained that the benefits of a fully vaccinated healthcare labor force-believed to be protecting health systems, vulnerable patient populations, and even HCWs themselves-achieved through mandates, if necessary, outweigh its potential harms. Informed by critical policy and discourse traditions, we examine the expert literature on vaccine mandates for HCWs. We find that this literature neglects evidence that contradicts official claims about the safety and effectiveness of COVID-19 vaccines, dismisses the science supporting the contextual nature of microbial virulence, miscalculates patient and system-level harms of vaccination policies, and ignores or legitimizes the coercive elements built into their design. We discuss the implications of our findings for the sustainability of health systems, for patient care, and for the well-being of HCWs, and suggest directions for ethical clinical and policy practice.

COVID-19 ethics: unique aspects and a review as of early 2024

COVID-19 presents a variety of ethical challenges in a set of arenas, arenas not always considered in past pandemics. These challenges include issues related to autonomy, distributive ethics, and the establishment of policies of equity and justice. Methods are a literature review based on regular editing of an online textbook during the COVID-19 outbreak and a literature review using key ethical terms. Patients are confronted with new issues related to autonomy. Providers need to expand their concepts of ethical issues to include decisions based on proportionality and public health ethics. The public health sector needs to assess the beneficence of alternative modes of disease control. The research community needs to redefine the concept of informed consent in emergent conditions. All elements of the medical spectrum-physicians, scientists, and the community-at-large including the pharmaceutical industry-need to consider the multifaceted methods for preventing future pandemics. This will require giving particular emphasis to public health funding and ending the documented discrimination that exists in the provision of proven therapies. The developing world is especially at risk for most of the ethical issues, especially those related to equity and justice. The ethical issues associated with the COVID-19 outbreak are not unique but provide a diverse set of issues that apply to patients, providers, social groups, and investigators. The further study of such issues can help with preventing future outbreaks.

Non-uptake of COVID-19 vaccines and reasons for non-uptake among healthcare workers in Uganda: a cross-sectional study

BACKGROUND

Vaccines play a crucial role in eradicating and containing disease outbreaks. Therefore, understanding the reasons behind vaccine refusal and associated factors is essential for improving vaccine acceptance rates. Our objective was to examine the determinants of COVID-19 vaccine non-uptake and explore the reasons for non-uptake among healthcare workers (HCWs) in Uganda.

METHODS

Between July and August 2021, we conducted a cross-sectional study among healthcare workers in primary healthcare facilities (private and government) in Entebbe Municipality, Uganda. Participants were recruited using convenience sampling, and consenting individuals received credentials to access an electronic database and complete a structured questionnaire. There were no established HCWs contact registers in the municipality, and the study was conducted during a national lock down, therefore, the HCWs who were on duty at the time of the study were approached. The survey questions were based on the '3Cs' model of vaccine hesitancy and focused on confidence, convenience, and complacency factors. Non-uptake of vaccines was defined as not having received any of the available vaccines in the country. We employed counts, percentages, and simple logit models to summarize the reasons for non-uptake of COVID-19 vaccines and to identify associated factors.

RESULTS

The study recruited 360 HCWs, 61.7% of whom were female, with an average age of 31 years (SD = 7.9). Among them, 124 (34.4%) healthcare workers did not receive any COVID-19 vaccine. Non-uptake of COVID-19 vaccines was independently associated with several factors, including age [35 + years adjusted odds ratio (aOR) = 0.30, 95% CI: 0.13-0.66 compared with 18-24 years], facility ownership [government, aOR = 0.22 (0.10-0.49) compared with private not-for-profit], previous testing for coronavirus [yes, aOR = 0.35 (0.19-0.65)], and previous involvement in COVID-19 vaccine activities [yes, aOR = 0.17 (0.10-0.29)]. The primary reasons cited for non-uptake of COVID-19 vaccines were related to a lack of confidence in the vaccines, such as concerns about side effects (79.8%) and the need for more time to understand the vaccines (89.5%), as well as the importance of weighing benefits and risks (84.7%) before being vaccinated. A smaller proportion, approximately 23%, cited reasons related to complacency and lack of convenience in accessing vaccination services.

CONCLUSION

The high proportion of non-uptake of COVID-19 vaccines among this population primarily stems from a lack of confidence and trust in the vaccines, coupled with insufficient time allowed for users to make informed decisions. This underscores the urgent need for ongoing monitoring and trend analysis of vaccine non-uptake to guide the development and implementation of strategies aimed at building and sustaining vaccine confidence. Adequate time should be allowed to explain benefits of vaccination to the population to allay fears that might exist before actual vaccination is rolled out.

Trait reactance as psychological motivation to reject vaccination: Two longitudinal studies and one experimental study

Anti-science attitudes can be resilient to scientific evidence if they are rooted in psychological motives. One such motive is trait reactance, which refers to the need to react with opposition when one's freedom of choice has been threatened. In three studies, we investigated trait reactance as a psychological motivation to reject vaccination. In the longitudinal studies (n = 199; 293), we examined if trait reactance measured before the COVID-19 pandemic was related to people's willingness to get vaccinated against COVID-19 up to 2 years later during the pandemic. In the experimental study (n = 398), we tested whether trait reactance makes anti-vaccination attitudes more resistant to information and whether this resistance can be mitigated by framing the information to minimize the risk of triggering state reactance. The longitudinal studies showed that higher trait reactance before the COVID-19 pandemic was related to lower willingness to get vaccinated against COVID-19. Our experimental study indicated that highly reactant individuals' willingness to vaccinate was unaffected by the amount and framing of the information provided. Trait reactance has a strong and durable impact on vaccination willingness. This highlights the importance of considering the role of trait reactance in people's vaccination-related decision-making.

Unraveling the association between vaccine attitude, vaccine conspiracies and self-reported side effects following COVID-19 vaccination among nurses and physicians in Jordan

BACKGROUND

The negative impact of vaccine conspiracies is linked with negative health behavior. The aim of the current study was to examine the association between attitudes toward booster COVID-19, influenza, and monkeypox (mpox) vaccinations with post-COVID-19 vaccine side effects, vaccine conspiracies, and attitude towards mandatory vaccination among nurses and physicians in Jordan.

METHODS

A structured closed-ended questionnaire was used to collect data on demographics, COVID-19 history, COVID-19 vaccine type and doses received, self-reported side effects post-COVID-19 vaccination, acceptance of booster COVID-19, seasonal influenza, and mpox vaccinations, attitudes towards mandatory vaccination, and beliefs in vaccine conspiracies.

RESULTS

The study sample comprised a total of 341 participants. Acceptance of yearly booster COVID-19 vaccination was expressed by 46.6% of the sample, while 73.3% accepted seasonal influenza vaccination, and only 37.0% accepted mpox vaccination. A higher frequency of self-reported side effects following the first COVID-19 vaccine dose was associated with embrace of vaccine conspiracies and vaccine type. For the second vaccine dose, a higher frequency of self-reported side effects was associated with the embrace of vaccine conspiracies, older age, and affiliation to private sector. In multinomial logistic regression analyses, the lower embrace of vaccine conspiracies was associated with lower odds of reporting side effects post-COVID-19 vaccination. The lower embrace of vaccine conspiracies and favorable attitude towards mandatory vaccination were associated with the willingness to get COVID-19, influenza, and mpox vaccinations.

CONCLUSION

The study findings highlighted the negative impact of embracing vaccine conspiracies on health-seeking behavior among nurses and physicians. The findings indicated that the willingness to get vaccinated was associated with lower endorsement of vaccine conspiracies. Additionally, the lower embrace of vaccine conspiracies was associated with a lower frequency of self-reported side effects following COVID-19 vaccination. These results emphasize the importance of addressing vaccine misinformation and promoting accurate information to ensure optimal vaccine uptake and public health outcomes.

Occupation-related factors affecting the health of migrants working during the COVID-19 pandemic - a qualitative study in Norway

BACKGROUND

The effects of the COVID-19 pandemic were more pronounced among migrants than in the majority population and went beyond those directly caused by the virus. Evidence suggests that this overburden is due to complex interactions between individual and structural factors. Some groups of working migrants were in vulnerable positions, overrepresented in essential jobs, under precarious work conditions, and ineligible for social benefits or special COVID-19 economic assistance. This study aimed to explore the experience of migrants working in Norway during the COVID-19 pandemic to gather an in-depth understanding of the pandemic´s impact on their health and well-being, focusing on occupation-related factors.

METHODS

In-depth personal interviews with 20 working migrants from different job sectors in Bergen and Oslo were conducted. Recruitment was performed using a purposive sampling method. Thematic analysis was used.

RESULTS

At the workplace level, factors such as pressure to be vaccinated, increased in occupational hazards, and increased structural discrimination negatively impacted migrants' health. Other factors at the host country context, such as changes in social networks in and out of the workplace and changes in the labour market, also had a negative effect. However, the good Norwegian welfare system positively impacted migrants' well-being, as they felt financially protected by the system. Increased structural discrimination was the only factor clearly identified as migrant-specific by the participants, but according to them, other factors, such as changes in social networks in and out of the workplace and social benefits in Norway, seemed to have a differential impact on migrants.

CONCLUSIONS

Occupational-related factors affected the health and well-being of working migrants during the pandemic. The pressure to get vaccinated and increased structural discrimination in the workplace need to be addressed by Norwegian authorities as it could have legal implications. Further research using intersectional approaches will help identify which factors, besides discrimination, had a differential impact on migrants. This knowledge is crucial to designing policies towards zero discrimination at workplaces and opening dialogue arenas for acknowledging diversity at work.

Healthcare professionals' attitudes to mandatory COVID-19 vaccination: Cross-sectional survey data from four European countries

Mandatory vaccinations are widely debated since they restrict individuals' autonomy in their health decisions. As healthcare professionals (HCPs) are a common target group of vaccine mandates, and also form a link between vaccination policies and the public, understanding their attitudes toward vaccine mandates is important. The present study investigated physicians' attitudes to COVID-19 vaccine mandates in four European countries: Finland, France, Germany, and Portugal. An electronic survey assessing attitudes to COVID-19 vaccine mandates and general vaccination attitudes (e.g. perceived vaccine safety, trust in health authorities, and openness to patients) was sent to physicians in the spring of 2022. A total of 2796 physicians responded. Across all countries, 78% of the physicians were in favor of COVID-19 vaccine mandates for HCPs, 49% favored COVID-19 vaccine mandates for the public, and 67% endorsed COVID-19 health passes. Notable differences were observed between countries, with attitudes to mandates found to be more positive in countries where the mandate, or similar mandates, were in effect. The associations between attitudes to mandates and general vaccination attitudes were mostly small to neglectable and differed between countries. Nevertheless, physicians with more positive mandate attitudes perceived vaccines as more beneficial (in Finland and France) and had greater trust in medical authorities (in France and Germany). The present study contributes to the body of research within social and behavioral sciences that support evidence-based vaccination policymaking.

Better to Be Unpaid than COVID-19 Vaccinated! A Qualitative Study on Italian Nurses Suspended from Work without Salary

In Italy, from April 2021, healthcare workers were required to receive the COVID-19 vaccine; if they refused it, an immediate unpaid suspension was implemented until they received the vaccine. Although there are numerous quantitative studies on the factors that influenced vaccine hesitancy during the COVID-19 pandemic, qualitative research on the causes of vaccine refusal is still missing. This research aimed to investigate the phenomenon of nurses who refused to receive COVID-19 vaccination despite being required to do so, as well as the reasons behind their refusal. Furthermore, the actions of those who abandoned this stance were explored. This was a qualitative study involving the methodological approach of grounded theory. Twenty-four nurses were interviewed virtually via Zoom from May to July 2022. Anti-vax behavior-as emerged from nurses' experiences-was based on seven themes: (1) job satisfaction, (2) the main sources of information on COVID-19, (3) the reasons for refusing the COVID-19 vaccine, (4) the attitudes of family members toward the COVID-19 vaccine, (5) previous experience with other vaccines, (6) firm opposition to the vaccine (unvaccinated nurses), (7) reluctant acceptance (vaccinated nurses). It was shown that it is imperative for health authorities to adopt timely, documented, transparent, and consistent communication when carrying out public health campaigns, especially for vaccination.

Barriers and facilitators to the provision of maternal health services at community health centers during the COVID-19 pandemic: Experiences of midwives in Indonesia

OBJECTIVE

To explore the experiences of midwives in Indonesia on the provision of maternal health services during the COVID-19 pandemic.

DESIGN AND METHODS

A qualitative descriptive study using focus group discussions was undertaken. A conventional content analysis was used to analyze the data. Coding categories were generated from the transcripts.

SETTING AND PARTICIPANTS

Twenty-two midwives from five community health centers of three regions in the Province of Jambi, Indonesia were included.

FINDINGS

The interviewees shared similar barriers and facilitators in delivering the services, including the unavailability of adequate protective equipment, the limitation of the number of services, and dealing with the new public health measures related to the COVID-19. Overall, midwives demonstrated a continued commitment to provide maternal health services during the pandemic.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Significant changes in service delivery have been made to comply with pandemic related restrictions. Despite the unprecedentedly difficult working environment, the midwives continue to provide adequate services to the community by implementing a strict health protocol. Findings from this study contribute to a better understanding of how the quality of the services changed, as well as how new challenges can be addressed and positive changes can be reinforced.