"To Protect Myself, My Friends, Family, Workmates and Patients...and to Play My Part": COVID-19 Vaccination Perceptions among Health and Aged Care Workers in New South Wales, Australia

"Communication about COVID-19 vaccines that is based on an understanding of factors influencing COVID-19 vaccine acceptance can build public trust and more effectively support the acceptance of COVID-19 vaccines."

Healthcare workers play a central role in public confidence in vaccines; their perceptions about the COVID-19 vaccine may influence not only their own but also the public's vaccination decisions. Globally, including in Australia, these personnel have been prioritised to receive the COVID-19 vaccine due to high occupational exposure risk and increased likelihood of transmitting the virus to vulnerable people. This paper presents findings from qualitative interviews with 19 health and aged care workers (HACWs) in New South Wales (NSW), Australia, which were conducted in order to understand the factors influencing HACWs' acceptance of COVID-19 vaccination.

The study revealed that HACWs reported a continuum of COVID-19 vaccination intentions, with 12 enthusiastically accepting and 7 hesitant. To explore these findings, the researchers drew on the World Health Organization (WHO) Behavioral and Social Drivers of COVID-19 Vaccination (BeSD) Framework, which groups factors influencing vaccination behaviour into either motivational factors (influenced by what people think and feel about vaccination and social processes) or practical issues surrounding access to vaccination.

In short, participants' acceptance of vaccination was primarily driven by their perceptions of COVID-19 vaccination (such as safety, risk and benefits) and by the information sources, people, and norms they trusted. For example:

• Accepting participants reported trust in science and research processes in general and, in particular, those underpinning COVID-19 vaccine development. Conversely, hesitant participants had many concerns about vaccine effectiveness and safety and questioned the speed of vaccine development. Some in that group perceived that the information about COVID-19 and COVID-19 vaccines had been scarce and not transparent. A few also reported misperceptions based on misinformation and conspiratorial thinking.
• Most participants reported confidence in vaccination in general, whereas hesitant participants reported low levels of confidence in COVID-19 vaccination and reported many concerns.
• Accepting participants were more likely to describe wanting to vaccinate to protect others at work, at home, and in the community. This sense of obligation to vaccinate was not reported by hesitant participants. A few reported confusion with the concept of herd immunity, which indicates that lack of knowledge is potentially contributing to some HACWs' poor sense of community values of vaccination.
• Accepting participants were more likely to describe the COVID-19 pandemic as serious, whereas hesitant participants were more likely to report that the pandemic risk in Australia was overstated or politicised.
• Accepting participants were more likely to perceive that, while COVID-19 vaccines come with some risks, the benefits of vaccinating greatly outweighed those risks. Conversely, hesitant participants were less likely to describe the benefits of COVID-19 vaccines and more likely to voice concerns.
• Accepting participants reported feeling they had a choice to vaccinate or not, considering COVID-19 vaccination to be a means to exercise personal agency around personal and public health. Conversely, hesitant participants discussed COVID-19 vaccination through a lens of limited choice and control.
• Some accepting participants reported knowledge gained from their clinical training and/or professional experiences, which helped instill confidence in the vaccines. Participants also reported accessing mainstream and social media, but some hesitant participants reported confusion with the COVID-19 vaccination content presented there.

In this study, HACWs' perceptions fell mostly under the BeSD motivational domains of "thinking and feeling" and "social processes". Accordingly, the researchers propose several communication strategies that may be helpful in addressing HACWs' vaccination acceptance.

• Doubts among hesitant individuals about the importance of whole-of-community vaccination - within the BeSD's "thinking and feeling" domain - can be addressed with educational campaigns and educational materials. Accordingly, resources could be developed to explain the communal benefits of vaccinating. Because some individuals may not be sufficiently motivated by such appeals, in their vaccination conversations with patients, public health communicators and clinicians should consider emphasising both the communal and individual benefits of vaccinating. The researchers suggest that COVID-19 vaccination public communication and resources suitable for use by clinicians should be in easy-to-digest formats - for example, short videos, infographics, and tables. Humour, both in the content and format of messages (e.g., short videos and cartoons), may also be considered.
• Negative information and social influences - categorised as "social process" factors in the BeSD framework - can be addressed by vaccine championing and strong recommendations to vaccinate from both institutions and trusted health providers. The researchers recommend developing communication campaigns to reach HACWs that feature trusted medical peers who clearly recommend vaccinating against COVID-19 (politicians were perceived by some participants as less trustworthy sources of information and, therefore, should not be featured in such campaigns). Such campaigns should offer opportunities for two-way communication with HACWs (e.g., via online or public forums, telephone hotlines, or social media) so that individuals are able to seek answers to their questions and have any misinformation debunked. Clinicians could also be recruited as "COVID-19 vaccination champions" and be provided with training and/or resources to facilitate their engagement with colleagues for promoting vaccinations.

The researchers suggest various directions for future research, such as further studies with HACWs from diverse backgrounds in order to provide accurate data on diverse motivational and practical drivers of evolving perceptions and attitudes towards COVID-19 vaccination.

In conclusion, this study has highlighted the importance of: publicly acknowledging that many HACWs make community-focused vaccination decisions; identifying and enabling HACWs' access to reliable, evidence-based, and trusted sources of vaccination information; making vaccination related information and concepts easy to understand; and actively debunking misinformation.