key: cord-0983269-fw4ewsbi
authors: Aci, Ozgur Sema; Kackin, Ozlem; Karaaslan, Selver; Ciydem, Emre
title: Qualitative examination of the attitudes of healthcare workers in Turkey regarding COVID‐19 vaccines
date: 2021-08-06
journal: Int J Nurs Knowl
DOI: 10.1111/2047-3095.12342
sha: 96f3c8052040d40cef8c301ed588f50434caa617
doc_id: 983269
cord_uid: fw4ewsbi

PURPOSE: The attitudes of healthcare workers toward COVID‐19 vaccines ensure that health services are able to run without interruption and potentially have a role in the messaging about vaccination that they convey to the public. Hence, healthcare workers’ attitudes ultimately have a significant role in controlling the pandemic. This study aimed to qualitatively investigate the attitudes of healthcare workers in Turkey in relation to COVID‐19 vaccines. METHODS: The study used the phenomenological approach. The sample consisted of 36 healthcare workers who were employed during the COVID‐19 pandemic. Data were collected online using focus group interviews. A total of four focus group interviews were conducted. FINDINGS: Following analysis of the data, the attitudes of healthcare workers in Turkey toward the COVID‐19 vaccine were divided into three themes: “influencing factors,” “priority group” and “trust.” CONCLUSIONS: Vaccination was found to create negative emotions among some of the healthcare workers. Their opinions about the COVID‐19 vaccines were affected by the negative emotions and burnout they experienced during the pandemic. In addition, they saw the vaccination process as impacted by contraindications and uncertainty about the duration of the protection, the balance of the benefits and harm of the vaccines, and by vaccine myths and prejudices about the country where the vaccine was developed. Healthcare professionals expressed the need for trust to be established in the whole vaccination process. They suggested that different vaccine options should be offered, that the appointment and process notification system for vaccination should be improved, that evidence‐based information about vaccines should be provided and that a safe environment should be created. PRACTICE IMPLICATIONS: 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.

The COVID-19 pandemic has created many problems in the economic, health and social arenas (Calderon-Anyosa & Kaufman, 2021; Hossain, 2021; Mehraeen et al., 2020a Mehraeen et al., , 2020b Mehraeen et al., , 2021 Seyed Alinaghi et al., 2020) . Vaccinations are currently the most effective approach available to overcome the adverse consequences of the pandemic (Murphy et al., 2021) . Nevertheless, vaccine hesitancy, a behavior that delays acceptance or rejects the vaccine, is increasingly regarded as a global health threat by the World Health Organization (WHO, 2019) .

Vaccination to protect the health and ensure the safety of healthcare workers who are playing the leading role in fighting the COVID-19 pandemic is vitally important not only for the continuous and safe execution of healthcare services but also for controlling the pandemic (Chang et al., 2020; Dooling et al., 2021; Kwok et al., 2021) . Due to factors such as constant exposure to patients and infection, lack of personal protective equipment, and insufficient infection control training, healthcare workers are at greater risk than any other group (Huang et al., 2020; Lai et al., 2020) . Healthcare workers are three times more likely to contract the disease than members of the wider community (Nguyen et al., 2020) . They are also at high risk for transmitting the disease (Gómez-Ochoa et al., 2021) . For all these reasons, vaccination of healthcare workers has become a priority, and healthcare workers were identified as the first group to be vaccinated (Dooling et al., 2021) .

Administration of COVID-19 vaccines has begun, and studies regarding their efficacy in providing protection are ongoing (Murphy et al., 2021) . However, even if vaccination studies are quickly finalized and effective vaccines identified, a large part of the population may still refuse to be vaccinated (Murphy et al., 2021) . A study conducted with samples from the adult populations of Ireland and the UK found that hesitancy against the COVID-19 vaccine was 35% in Ireland and 31% in the UK (Murphy et al., 2021) . Similarly, in the USA, 25% reported that they would not be vaccinated against COVID-19 when the vaccine became available (Tyson, Johnson, & Funk, 2020) .

The European Center for Disease Prevention and Control (eCDC) (2015) says healthcare workers are considered a reliable source of information about vaccination (Karafillakis et al., 2016) , whereas the WHO (2020) has emphasized the role of healthcare workers in developing public trust in vaccines. It is believed that healthcare workers can have a positive impact on the public regarding the administration of the COVID-19 vaccine and eliminate patients' concerns about the newly developed vaccines (Kwok et al., 2021) . Nevertheless, studies have highlighted that vaccine hesitancy also exists among healthcare workers (Dror et al., 2020; Kwok et al., 2021) . It has been shown that 37% of nurses in China and 23.1% of healthcare workers in France do not intend to be vaccinated against COVID-19 (Gagneux-Brunon et al., 2021; Kwok et al., 2021) . Likewise, it was determined in Croatia (2021) that one out of six healthcare workers had vaccine hesitancy, with nurses more hesitant than physicians (Tomljenovic et al., 2021) . A study conducted in Israel showed that healthcare workers who provided care to patients diagnosed with COVID-19 had positive attitudes toward vaccination, whereas healthcare workers who did not treat this group had negative attitudes (Dror et al., 2020) . The eCDC reports that vaccination rates among healthcare workers range from 2.2% to 29% (eCDC, 2020) . Some of these studies were conducted before COVID-19 vaccines became available, but others have shown high rates of hesitancy even since the vaccine became available (Qunaibi et al., 2021; Tomljenovic et al., 2021) . It is suggested that even if the vaccination of healthcare workers was made mandatory, their vaccine hesitancy might still adversely influence society as they could recommend against vaccination and damage the public's trust in vaccination (Verger et al., 2015) . Although quite extensive models have been developed for testing vaccine hesitancy, the stressors and psychosocial problems that healthcare workers have been exposed to during the COVID-19 pandemic may influence their vaccination process (Betsch et al., 2018; Kackin et al., 2020; Kwok et al., 2021) . In addition, existing studies mainly address the influenza vaccine, and studies investigating the COVID-19 vaccine are quantitative studies focused on prevalence data about intention to be vaccinated rather than considerations of individual factors. The success of the vaccination program requires a determination of the reasons for the vaccine hesitancy of professionals. Developing strategies to address these concerns is critical (Maraqa et al., 2021) . Thus, there is a need to explore, in depth, the attitude of healthcare workers toward the COVID-19 vaccine, including their perceptions of information about the vaccine. A better explanation of the multiple factors and complex structures that lead to vaccine hesitancy among healthcare providers is needed as this could play a key role in designing effective responses (Dube, 2017) . The aim of this study is, therefore, to qualitatively investigate the attitudes of healthcare workers in Turkey in relation to the COVID-19 vaccine.

This study observed the Standards for Reporting Qualitative Research guidelines (COREQ).

The phenomenological approach was used in this study. This method focuses on phenomena of which we are aware but lack any in-depth or detailed understanding. Phenomena may be events, situations, perceptions, orientations, experiences, concepts, and more. The phenomenological approach focuses on individual experience: the researcher aims to investigate the participant's individual perceptions and the meanings they attribute to the phenomenon as well as their personal (subjective) experiences (Creswell, 2020) . Focus group interviews are conducted within a framework of predetermined guidelines. The method prioritizes the subjective responses of interviewees, and attention is paid to the participants' discourse and to the social context of that discourse (Merriam & Tisdell, 2015) . The purpose of the focus group interview is to obtain in-depth, detailed, and multidimensional qualitative information about the perspectives, lives, interests, experiences, tendencies, thoughts, perceptions, feelings, attitudes, and habits of the participants in relation to the subject under discussion (Merriam & Tisdell, 2015) . In this study, the phenomenological method was selected to examine, in-depth, the attitudes of healthcare workers in Turkey in relation to COVID-19 vaccines.

This study was performed by three female and one male researchers, all trained in qualitative research methods. Although the participants knew the researchers, no conflictual relationship existed among them.

To promote reflextivity as is essential in qualitative research, the research team held regular meetings throughout data collection and analysis to assure their own assumptions were not influencing the findings expressed by the participants.

The study was conducted between January 17 and 30, 2021, using online platforms with participants from different provinces of Turkey.

The purposeful sampling technique was used in this study to collect information from individuals who had experienced similar situations. Healthcare workers who worked in any province in Turkey, who were employed during the pandemic and were 18 years or older were included in the study. The researchers contacted 40 healthcare workers by phone and e-mail before starting the study. Four of the potential participants reported that they would be unable to participate due to work situations changing at the last minute. Data saturation was reached by the end of four focus group interviews performed with a total of 36 healthcare workers, including 12 women and 24 men, who constituted the sample for the study (N = 36).

The data were collected with a survey form and from a semistructured interview. The survey form was prepared by the researchers and was distributed online (Barry et al., 2020; Karafillakis et al., 2016) . 

The data for the research were collected from focus group interviews.

Because of measures taken during the COVID-19 pandemic, the interviews were held online. Participants had completed the online survey form sent to their e-mail addresses prior to the interviews. Each focus group interview involved nine participants, a moderator, and an assistant. A semistructured interview form was used, and a total of four interviews were performed. A pilot study was performed first with a group of nine people who were not included in the study sample but were in the target group. This tested the data collection tools and the interview process. Interviews were conducted in quiet home environments, considered suitable for the interviews. The healthcare workers who met the criteria for inclusion in the study were informed about the research. Before the interview, the participants were reminded of the objective of the study. Interviews began after a warm-up exercise was performed to make it easier for group members to express themselves. Each focus group interview lasted for 80-90 minutes.

During the interview process, the statements of participants were recorded with written notes and a voice recorder. The voice records were then transcribed, and the transcripts were confirmed by the participants.

The voice records collected from the interviews were transcribed by OK and EC. OSA and SK checked the consistency and accuracy of the transcripts. The transcripts obtained from the first focus group interview were encoded by all the researchers, independently. Afterward, the remaining transcripts were encoded by OSA and OK, and all the researchers met to agree on the codes and categories. These codes and categories were used to create themes. The findings of the study were examined and confirmed by an academic who was not one of the researchers and who is an expert in the field. The data were analyzed by using the MAXQDA 20.0 program and the phenomenological analysis steps of Colaizzi (1978) . The steps of the analysis process are shown in Table 1 (Colaizzi, 1978) .

The study was approved by the Noninvasive Clinical Research Ethics Committee (X-Decision No. X) and the Scientific Research Platform of the Republic of Turkey, Ministry of Health. Prior to the focus group interviews, verbal consent and written consent were obtained from the participants via the online survey form (1995 Declaration of Helsinki, TA B L E 1 Colaizzi's method of data analysis 1. Transcripts were read several times and short notes were taken. Thus, the meaning and emotion of the phenomenon were understood. 2. The important statements were chosen. 3. Important statements with common meanings were rendered systematic. 4. The systematic subthemes were organized by themes and categories. 5. The results obtained were combined with the life experiences of the individuals. 6. The basic conceptual structure of the phenomenon was determined. 7. The results were confirmed to accurately represent the experiences of healthcare workers.

as revised in Brazil, 2013). The written notes and sound records obtained were encrypted in the computer environment.

In this study, trustworthiness was achieved through the criteria of credibility, transferability, dependability, and confirmability, as proposed by Lincoln and Guba (1985) . Credibility was achieved by using the MAXQDA 20.0 program for the analysis of the data, by obtaining participant confirmation, by the researchers holding regular meetings relating to the study process, and by including the qualifications of the researchers in the text. In addition, credibility was achieved by quoting participant statements in the text, by ensuring consistency between coders, and by ensuring that a variety of data collection tools were used. The working process and method were presented clearly and precisely to ensure transferability. Dependability was achieved by having an expert who was not involved in the study examine all data obtained.

Confirmability was achieved by using multiple data collection methods and by different researchers encoding the data independently.

The findings of the research are presented in two parts. Part 1 contains the individual demographics of the healthcare workers, and Part 2 addresses the themes, subthemes, and categories obtained from the interviews.

The majority of the healthcare workers participating in the study were male and married, with an average age of 34 ± 19 years. In addition, 52.8% of the 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. The individual demographics of the healthcare workers are given in detail in Table 2 .

Following the analysis of the data, the attitudes of healthcare workers in Turkey toward the COVID-19 vaccine were allocated to one of three themes: "influencing factors," "priority group," and "trust." The themes, subthemes, and categories are described below.

The theme of "influencing factors" contained five subthemes, including "negative emotions," "social media," "vaccine and vaccination process,"

"political processes," and "intention to be vaccinated."

Some participants emphasized that they felt anxiety, fear, suspicion, 

The theme of "priority group" contained two subthemes, including "attitude" and "intention to be vaccinated."

Participants discussed the decision of the Ministry of Health to "vaccinate healthcare workers first." Some participants supported this decision, whereas others reported that they did not, feeling they were being used for advertising or as guinea pigs. 

In this study, which aimed to qualitatively investigate the attitudes of healthcare workers in Turkey toward COVID-19 vaccines, their attitudes were grouped into three themes: influencing factors, priority group, and trust.

Some of the participants stressed that they felt negative emotions and experienced burnout, and that these affected their attitudes to vaccination. Other studies confirm that healthcare workers feel anxiety, fear, and worry about vaccination (Barry et al., 2020; Di Martino et al., 2020; Gadoth et al., 2020; Savaş & Tanrıverdi, 2010) . During the COVID-19 pandemic, about half of nurses and a third of radiology technicians and pharmacists in Japan were reported to meet burnout criteria (Matsuo et al., 2020) . Vaccine myths and confusion are identified as other important factors affecting intention to be vaccinated (Lewandowsky et al., 2021; Sahoo et al., 2020) . The WHO (2019) identified vaccine hesitancy as one of the top ten threats to global health, and one of the reasons for the hesitation was reported as the "spread of myths about vaccines"

(WHO, 2019). Due to the very recent emergence of the COVID-19

infection and its impact on almost all countries of the world, myths about its spread and transfer are far greater than for diseases such as leprosy and tuberculosis (Sahoo et al., 2020) . Most people can access social media, and this makes it possible for myths to spread quickly and extensively. Myths may lead to confusion and endanger the health of individuals by inhibiting required practices (Sahoo et al., 2020) .

It is evident that healthcare workers face dilemmas about being vaccinated due to institutional pressures and possible dismissals. In

Italy, due to increasing vaccine hesitancy among health workers and falling vaccination rates, mandatory vaccination was introduced in some regions (Di Martino et al., 2020) . In some countries, the use of a "vaccine passport" has been proposed, a document proving vaccination during the pandemic. The intention was that individuals holding this passport could participate in social, economic, and cultural activities without restriction. However, it is noted that this could create difficulties in the scientific, practical, egalitarian and legal areas (Grech et al., 2020; Phelan, 2020) . The dilemmas faced by healthcare workers in this study may arise from the desire of institutions to implement the vaccination process quickly and to follow policies that would promote vaccination. These practices may have put pressure on healthcare workers (Di Martino et al., 2020) . Some participants mentioned that statements from the Ministry of Health and images on social media of healthcare workers being vaccinated had a positive impact on their attitude toward vaccination. Studies suggest that the trust relationship between healthcare and politicians needs to be strengthened before healthcare workers will consent to be vaccinated (Larson, 2015; Paterson et al., 2016) . It is recommended that both traditional and social media be used to create strong vaccination campaigns. Many studies confirm that doctors are the most important influencers in decisions to be vaccinated (Kempe et al., 2011; Smith et al., 2006) . Some participants reported that they were biased against the country in which the vaccine was developed and would prefer to wait for a domestic vaccine. Motta reached the similar conclusion that Americans would tend to accept vaccines if they were produced in the United States rather than in China, and this related to the suspicion that the Chinese government was involved in "creating" or "spreading" the virus (Motta, 2021 

Some participants noted that the protection of family and society, the prevention of loss of life and the ending of the pandemic all depend on vaccination, so they trusted the vaccine and wanted to be vaccinated. A study by Prematunge et al. (2014) shows that altruism, or the desire of healthcare workers to protect their loved ones, was the main reason for their accepting vaccination. Studies report that the beliefs of healthcare workers that vaccination is the most effective way to end the epidemic, that they are at high risk, and that there is a risk of their infecting patients are the main factors motivating them to be vaccinated (Barry et al., 2020; Prematunge et al., 2014) . Other studies report that the percentage of health workers desiring to be vaccinated during the COVID-19 pandemic is much higher than that in the general population . In contrast, Dror et al. (2020) highlight that healthcare workers trusted the COVID-19 vaccine less than the general population did, and that nurses were more hesitant about the vaccine than doctors or the general population. This study reports that healthcare workers are willing to be vaccinated for reasons such as unemployment and job insecurity, school closures, difficulty in caring for their children, and the desire to end the COVID-19 pandemic (Dror et al., 2020) .

Some participants supported the Ministry of Health's decision to vaccinate healthcare workers first, whereas others reported that they did not support this decision because they felt they were being used for advertising and as guinea pigs. Other studies note that the reasons for healthcare workers rejecting the COVID-19 vaccine include the lack of adequate safety and efficiency data, side effects, the belief that the vaccine will be ineffective and concerns regarding the safety of a hurriedly developed vaccine (Barry et al., 2020; Dror et al., 2020) . During the last decade, especially, distrust, false information, and conspiracy theories about vaccines have been common in many countries. For this reason, it is important to address the newness, the rapid development, and the fear of negative effects from vaccines, all of which cause hesitancy among the healthcare workers who are seen as the priority group for vaccination (Barry et al., 2020) .

Participants reported their expectations that the vaccine would provide a high protection rate, and that they would be prepared to 

In this study, the data collection tools and the interview process were first tested with a pilot study. The fact that healthcare workers from different institutions and professions were included in the same focus group allowed differing attitudes to be revealed. However, due to the pandemic, the meetings were held via an online system, and this may have inhibited some participants from fully expressing themselves. To minimize this situation, warm-up exercises were performed before each focus group interview. In addition, even though participants were assured of confidentiality, some participants may have been hesitant to express negative views on the vaccine due to government policies supporting vaccination. Due to the limitations of a qualitative design, further research would be helpful.

Practices that address the psychological issues of healthcare workers in their fight against negative emotions and burnout will contribute positively to the vaccination program. In fighting vaccine hesitancy among healthcare workers, future research should test strategies that ensure the careful execution of vaccination programs, the correct and effective use of social media, transparent and precise management of political processes, the provision of evidence-based information, and the provision of training activities related to vaccine myths and prejudices about the country where the vaccine was developed.

Healthcare workers' attitudes toward COVID-19 vaccines are affected by the negative emotions and burnout that they have experienced during the epidemic. In addition, the vaccination process is affected by the contraindications and uncertainties concerning the duration of the protection, the balance of benefits and harms from the vaccine, and also by vaccine myths and prejudices about the country where the vaccine was first developed. Healthcare professionals do have expectations that trust in the vaccine can be developed. They suggest that different vaccine options should be offered, that appointment and process notification systems for vaccination should be improved, that evidence-based information about vaccines should be provided, and that a safe environment should be created for the vaccination process. 

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The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

We would like to thank the healthcare workers and Dercan Gencbas for participation in this study.

Ozgur Sema Aci PhD https://orcid.org/0000-0003-1321-0579Ozlem Kackin PhD candidate https://orcid.org/0000-0003-1720-0343