Healthcare workers’ attitudes on mandates, incentives, and strategies to improve COVID-19 vaccine uptake: A mixed methods study

Figures & data

Figure 1. Timeline of COVID-19 in Massachusetts and research study events.

Table 1. Demographics of interview and survey participants.

	Interviews (N=52)	Survey (N=209)
	n (%)	n (%)
Age (years)^1
18-35	12 (23)	85 (41)
36-45	11 (21)	58 (28)
46-55	19 (37)	44 (21)
≥56	10 (19)	23 (10)
Gender
Female	41 (79)	170 (81)
Male	11 (21)	37 (18)
Transgender/non-binary	0	2 (1)
Race/Ethnicity
Asian	3 (6)	19 (9)
Black/African-American/Haitian	9 (17)	20 (10)
Caucasian	29 (56)	152 (73)
Mixed race	3 (6)	4 (2)
Prefer not to say	8 (15)	14 (6)
Hispanic
Yes	11 (21)	16 (8)
No	29 (56)	186 (89)
Prefer not to say	12 (23)	7 (3)
Country of birth
United States	36 (69)	170 (81)
Outside United States	16 (31)	39 (19)
Household number
1	5 (10)	19 (9)
2	9 (17)	49 (23)
3-7	38 (73)	141 (68)
Religion
None	14 (27)	112 (54)
Christianity	35 (67)	68 (33)
Other^2	3 (6)	29 (14)
Healthcare worker role
Advanced Practice Provider (NP, CNM, PA)	8 (15)	14 (7)
Emergency Medical Technician/Paramedic	6 (11)	18 (9)
Medical or Patient Care Assistant	2 (4)	14 (7)
Nurse (RN, LPN)	5 (10)	38 (18)
Physician	19 (37)	71 (34)
Social worker/Mental health specialist	1 (2)	14 (7)
Other^3	11 (21)	40 (19)
Healthcare setting
Ambulance	6 (11)	16 (8)
Hospital	24 (46)	129 (62)
Outpatient clinic	17 (33)	47 (23)
Other^4	5 (10)	17 (8)
Area of healthcare
Emergency	9 (17)	27 (13)
Family medicine	6 (11)	10 (5)
ICU/critical care	4 (8)	13 (6)
Internal medicine	3 (6)	18 (9)
Obstetrics/gynecology	11 (21)	23 (11)
Pediatrics	5 (10)	67 (32)
Other^5	14 (27)	51 (24)
Work location^6
Cape and Islands/South Shore	7 (14)	33 (16)
Central MA/Western MA	2 (4)	17 (8)
Greater Boston metropolitan area/North Shore	43 (82)	159 (76)

MA = Massachusetts.

¹Age; Interviews: 18–25 years (n = 4), 26–35 years (n = 8), 56–65 years (n = 8), ≥66 years (n = 2). Survey:18–25 years (n = 5), 26–35 years (n = 81), 56–65 years (n = 21), ≥66 years (n = 2).

²Other religion; Interviews: Judaism (n = 3). Survey: Hindu (n = 8), Islam/Muslim (n = 2), Judaism (n = 10), Judaism/Buddhism (n = 1), Meditation/The Golden Rule/Spirituality (n = 2), Orthodox (n = 1), Not specified (n = 4).

³Other healthcare worker role; Interviews: Clinical Support Specialist (n = 1), Community health worker/Wellness advocate (n = 2), Director of Interpreter Services (n = 1), Environmental Services (n = 1), Patient Navigator (n = 1), Public Safety Officer (n = 2), Laboratory director/Research scientist (n = 1), Respiratory Therapist (n = 1). Survey: Dietician (n = 2), Laboratory director/Research scientist (n = 7), Lactation Consultant (n = 1), Pharmacist/Pharmacy technician/Pharmacy liaison (n = 5), Phlebotomist (n = 4), Physical/Occupational therapist (n = 4), Program manager/Administrator (n = 8), Imaging technician (n = 2), Not specified (n = 7).

⁴Other healthcare setting; Interviews: Academic (n = 2), Community (n = 1), Homecare agency (n = 1), Remote (n = 1). Survey: Academic (n = 1), Dental setting (n = 1), Health Department (n = 2), Nursing home/Assisted living facility (n = 2), Remote (n = 2), School health center (n = 2), Multiple (n = 3), Not specified (n = 4).

⁵Other area of healthcare; Interviews: Ambulatory (1), Nursing home/Assisted living facility/Elder care (n = 1), Research (1), Orthopedic Surgical Practice (1), Primary Care (1), Psychiatry (1), Public Health (1), Renal Medicine (1), Social Work (1), Not specified (n = 5). Survey: Administration (n = 2), Anesthesiology/Surgery (n = 6), Behavioral Health (n = 1), Dentistry (n = 1), Inpatient (n = 5), Laboratory/Research (n = 6), Neurology (n = 1), Nursing home/Assisted living facility/Elder care (n = 1), Public health (n = 3), Radiology (n = 1), Multiple (n = 1), Not specified (n = 23).

⁶Work location; Interviews: Cape and Islands (n = 1), Central MA (n = 1), South Shore (n = 6), Western MA (n = 1), Greater Boston metropolitan area (n = 42), North Shore (n = 1). Survey: Cape and Islands (n = 4), South Shore (n = 29), Central MA (n = 11), Western MA (n = 6), Greater Boston metropolitan area (n = 151), North Shore (n = 8).

Table 2. Key themes and example quotes from interviews and surveys.

Key theme	Illustrative quotes
COVID-19 vaccine mandates	“ … on one hand, I feel like it should be mandatory … but also too, I feel like people should have the freedom to decide on their own, you know.” (P10-EMT, interview) “Vaccine requirements are not new in healthcare. We can’t work at the hospital without an MMR or a flu shot each year. The way this has been politicized is disgusting.” (123-Pediatric MD, survey) “Vaccines save lives and are proven effective. They have been mandated to attend public schools and colleges for years. This seems like an arbitrary vaccine to fight and the biggest issue I have is that unlike choosing not to wear a seatbelt, choosing not to vaccinate can hurt others who don’t have the option to get vaccinated. Putting others at risk unnecessarily should not be allowed in a healthcare setting. We have to get PPD testing and flu shots too. This is not different.” (156-Dietician, survey) “We must all work together to end this. It isn’t about the individual, it’s the “collective we.” (53- Advanced Practice Provider, survey) “Vaccination mandates are ruining healthcare. We have body autonomy over everything else in regards to our health, but coercing people to get vaccinated is unethical, unconstitutional and deplorable.” (205-ICU Nurse, survey) “I am fully vaccinated but I resent the mandate on boosters – especially termination for noncompliance.” (125-Imaging technician, survey)
COVID-19 vaccine incentives	“Your job is to take care of people you don’t, you shouldn’t need an incentive for that.” (P12-Family Medicine MD, interview) “We shouldn’t be incentivized to do the right thing, I think that sends the wrong message.” (P01-OBGYN MD, interview) “Incentives can be effective but also cause people to become suspicious of the vaccines.” (52-ICU Advanced Practice Provider, survey)
Strategies to improve COVID-19 vaccination rates	“I think public health messaging um that’s, you know, sort of culturally and linguistically competent … I think that that’s a really important one.”(P04-Midwife, interview) “ … I am discussing [vaccines] because I care about them and their family. That I did it for my community and patients.” (173-Pediatrics Nurse, survey)
Healthcare workers cited areas for improvement with the COVID-19 vaccine rollout.	“I think each person who’s declining has, unfortunately, a unique reason why. And that’s where the one-on-one conversation with a trusted source and whether that trusted source is someone that you’ve known for a long time, whether it’s someone that’s like you, whether it’s someone who has a familiar background to you, culturally … ” (P07-Family Medicine MD, interview) “Provide information on safety of mRNA vaccines, importance of preventing infection in vulnerable populations including pregnant patient.” (206-Pharmacist, survey) “ … just to be transparent because I think one of the reasons people don’t trust it is because people aren’t being clear about the potential side effects. And if you’re just upfront with people about it and they know what they’re getting themselves into then they feel more comfortable with it.” (P16-Social worker/Mental health specialist, interview) “Bring vaccines to the people. Don’t make them come to you.” (151-Researcher, survey) “[EMTs should be prioritized for vaccination because] there is no six feet social distancing in the back of an ambulance and even with all our PPE, we still have first responders becoming sick (R01-EMT, interview).”

Table 3. Attitudes toward COVID-19 vaccine and booster mandates and masking policies.

	n	%
COVID-19 vaccine mandates in healthcare settings (n = 209)
I fully support them	131	62.7
I support them if the option for non-vaccination is masking/testing, but do not support them if the consequence of non-vaccination is job termination	61	29.2
I do not support them under any circumstances	14	6.7
Other	3	1.4
COVID-19 booster mandates in healthcare settings (n = 209)
I fully support them	118	56.5
I support them if the option for non-vaccination is masking/testing, but do not support them if the consequence of non-vaccination is job termination	66	31.5
I do not support them under any circumstances	21	10.1
Other	4	1.9
Staff shortages due COVID-19 vaccine mandates
Yes	84	40.2
No	59	28.2
Not sure	66	31.6

Table 4. Effectiveness of strategies to improve COVID-19 vaccination and booster uptake (n = 209).

	Not effective	Somewhat effective	Effective/ Very effective
	n (%)	n (%)	n (%)
COVID-19 vaccination
Addressing misinformation	15 (7.2)	29 (13.9)	165 (78.9)
Tailored community outreach in areas with lower vaccination rates	15 (7.2)	34 (16.3)	160 (76.6)
Discussing vaccine safety	15 (7.2)	40 (19.1)	154 (73.7)
Incentives	25 (12.0)	41 (19.6)	143 (68.4)
One-on-one conversations with medical providers	15 (7.2)	53 (25.4)	141 (67.5)
Mandates	46 (22.0)	43 (20.6)	120 (57.4)
Increasing access to vaccinations	33 (15.8)	60 (28.7)	116 (55.5)
Increasing awareness of vaccine benefits	30 (14.4)	70 (33.5)	109 (52.2)
Public service announcements	47 (22.5)	88 (42.1)	74 (35.4)
COVID-19 booster
Addressing misinformation^1	19 (9.1)	36 (17.3)	153 (73.6)
Tailored community outreach in areas with lower vaccination rates^1	17 (8.2)	41 (19.7)	150 (72.1)
One-on-one conversations with medical providers	18 (8.6)	41 (19.6)	150 (71.8)
Increasing awareness of the need/eligibility for boosters	18 (8.6)	43 (20.6)	148 (70.8)
Increasing access to boosters	24 (11.5)	43 (20.6)	142 (67.9)
Incentives	28 (13.4)	40 (19.1)	141 (67.5)
Mandates	49 (23.4)	39 (18.7)	121 (57.9)
Public service announcements	38 (18.2)	75 (35.9)	96 (45.9)

¹n=208.