Emergency practitioners' motivations and acceptance of COVID-19 vaccination

Methods

A cross-sectional survey was distributed to assess attitudes of prehospital practitioners towards the COVID-19 vaccine, as well as their underlying reasons to receive or defer vaccination.

The survey link was distributed to EMS professionals via email listservs, and popular social media outlets were also used for distribution. Survey responses were collected from 28 April 2021 to 24 May 2021. Data were collected and managed via Qualtrics survey software. Survey participation was voluntary, and responses were collected anonymously. Respondents were not compensated for their participation, and could skip any question and end the survey at any time.

Exclusion criteria were being aged <18 years and not working in EMS. This study was reviewed by an institutional review board and was deemed exempt from board review in accordance with federal regulations.

Results

A total of 1087 survey responses were collected. Seventy were removed from analysis because the person responding did not currently work in EMS. As participants were allowed to skip survey questions, the number of answers per question varies.

Of all respondents, nearly 92% were white, approximately 65% were men and the highest proportion by age fell into the 25–34 years age group (27%) (Table 1). Additionally, a majority of participants worked in EMS full time (81%) and educational backgrounds included some college (28%), an associate's degree (25%) or a bachelor's degree (28%) (Table 1). The majority of respondents held a paramedic certificate (62%), followed by an EMT certificate (27%), with the commonest length of EMS experience being either 5–10 years (22%) or >20 years (29%) (Table 1).

When questioned about COVID-19 experiences, 19% of respondents reported having been personally diagnosed with COVID-19 (Table 2). Additionally, participants reported COVID-19 diagnoses within their families (46%), friend groups (88%) and patients (87%), and COVID-19 related deaths with their families (10%), friend groups (25%) and patients (49%) (Table 2). One-third of participants (33%) reported that they had not received any COVID-19 vaccine, while 65% had received a full vaccine dose (Table 3) (Figure 1).

The participants who had not received a COVID-19 vaccine (n=318) were asked how likely it was that they would receive the vaccine in the future. A large majority (81%) stated that they were unlikely or very unlikely to receive a COVID-19 vaccine while 5% stated that they were likely or very likely to receive one in the future (Table 4). Furthermore, nearly 25% were unlikely or very unlikely to recommend a COVID-19 vaccine to family and friends, while 53% reported they were likely or very likely to recommend it (Figure 2).

Vaccination acceptance increased as both education and certification levels rose. Among respondents with a bachelor's degree, 76% had received at least one dose of the COVID-19 vaccine, while 55% of those with a high diploma had received a vaccine (Figure 3). Similarly, 72% of paramedics had received a vaccine dose compared to 60% of EMTs (Figure 4).

Respondents were 87% more likely to have received a COVID-19 vaccine if they had been previously diagnosed with the disease (OR 1.873; p<0.0001). They were also 35% more likely to have received a vaccine if they had experienced the death of a patient to the disease (OR 1.350; P=0.030) (Table 5).

Age and education level were also statistically significant factors for vaccine acceptance. When compared to those aged 25–34 years, the 45–54 age group was twice as likely to have received a vaccine (OR 2.08; P<0.0001), the 55–64 age group 2.5 times more likely (OR 2.498; p<0.0001) and the 65–74 age group nearly five times as likely to have received a COVID-19 vaccine (OR 4.812; P=0.013) (Table 5). Additionally, compared to participants with an associate's degree, those with a bachelor's degree were 67% more likely to have received the vaccine (OR 1.67; P=0.008) and those with a master's degree were 2.5 times as likely to have received a COVID-19 vaccine (OR: 2.55; p=0.001) (Table 5).

Participants were 32% less likely to have received a COVID-19 vaccine if there had been a COVID-19 diagnosis within the family (OR 0.676; P=0.005). EMTs were 37% less likely than paramedics to have been vaccinated (OR 0.631; P=0.003) and full-time workers were 35% less likely than part-time workers to have received a COVID-19 vaccine (OR 0.653; P=0.025) (Table 5).

Respondents were presented with a Likert scale to rate their agreement with predetermined reasons depending on their personal vaccine decision. Of the participants who had received at least one dose of a COVID-19 vaccine (n=648), more than 91% reported (agree or strongly agree) a desire to protect family/friends as a reason to receive the vaccine (Table 6) (Figure 5). Others reported reasons including stopping the spread of the virus (86%), protection of self (86%) and protection of patients (81%). Additionally, 76% of respondents reported that they trusted the efficacy of the vaccine, and 61% trusted the CDC's information regarding the severity of the disease (Table 6) (Figure 5).

Among the respondents who had not received a COVID-19 vaccine (n=318), 94% cited the lack of information on the vaccines' long-term effects as the primary reason for deferring the vaccine (Table 7) (Figure 6). Most of these participants reported a belief that the vaccine was developed too quickly (85%), that it did not provide complete protection from the virus (82%) and a lack of trust in the CDC's information regarding COVID severity (74%) (Table 7) (Figure 6). A majority (57%) reported the vaccine posed greater risk than the virus and only 8% of these respondents planned to receive the vaccine in the future (Table 7) (Figure 6).

Discussion

In the EMS Agenda for the Future, Delbridge et al (1998) acknowledged public education as a ‘critical activity for EMS’, while also stressing the importance of incorporating concepts of injury and illness prevention into EMS education and behaviour, particularly to ‘develop and maintain a prevention-oriented atmosphere’ in EMS. It is imperative that EMS professionals continue advocating evidence-based best practices and promoting informed behaviour, such as supporting widespread vaccination during a global pandemic.

At the time of this survey, two-thirds of respondents had received partial or full COVID-19 vaccination. This matches the findings of previous surveys that identified the perceived acceptance of a COVID-19 vaccine among health professionals (Shaw et al, 2021; Shekhar et al, 2021) and the public (Malik et al, 2020). These findings suggest that most people are generally accepting of a COVID-19 vaccine. Until this study, the acceptance of and attitudes towards the COVID-19 vaccine specifically among EMS professionals had not been explored. This study identified several factors and intentions that affect vaccine acceptance among EMS professionals.

The findings of this study demonstrate the widespread impact this disease has had on frontline prehospital providers. Nearly 9 in 10 respondents said they personally knew someone who had been diagnosed with COVID-19, 87% reported caring for a COVID-19-positive patient and nearly 50% had experienced the death of a patient due to the disease. Both the clinical and personal experiences of prehospital providers were statistically significant predictors of their propensity to receive the vaccine. Respondents who had been personally diagnosed with COVID-19 were 87% more likely to receive the vaccine than those who had not. EMS professionals were also 35% more likely to be vaccinated if they had cared for a COVID-19-positive patient.

A prehospital provider's level of certification and education also proved to be key predictors for vaccine status. Compared to paramedics, EMTs were 37% less likely to have received a COVID-19 vaccine. Additionally, in comparison to those with an associate's degree, respondents with either a bachelor's or master's degree were more likely to report receiving a vaccine. This supports numerous studies demonstrating that higher education is a social determinant associated with increased COVID-19 vaccination rates (Fisher et al, 2020; Malik et al, 2020; Shekhar et al, 2021).

Compared to younger age groups, vaccine acceptance is demonstrably higher among older age groups. These findings mirror vaccine demographic data published by the CDC (2021). This continues to support the troubling trend of vaccine hesitancy or indifference among younger populations (CDC, 2021; Shaw et al, 2021; Shekhar et al, 2021). Additionally, vaccinated respondents cited a desire to protect their families, themselves and their patients as well as a desire to return to normalcy as reasons to receive the vaccine.

Building confidence in the safety and efficacy of COVID-19 vaccines is critical for promoting vaccine acceptance among practitioners and the public. Data continue to show that health professionals are highly trusted sources of information for COVID-19 vaccines, and can serve as important liaisons to promote vaccine acceptance (Altman, 2021; Malik et al, 2020). Of the one-third of respondents who reported they had not received a COVID-19 vaccine, 81% indicated they were unlikely to receive a vaccine in the future. Our data support the findings of Hamel et al (2021b) that adults who were reluctant to receive a COVID-19 vaccine when they first became available are unlikely to change their decision.

It is important to understand the underlying motivations for this decision to develop methods to overcome these hurdles. Non-vaccinated respondents in the present study echo concerns documented in previous studies, citing scepticism regarding the virus' severity, safety of the vaccine, and information reported by the CDC/government (Shekhar et al, 2021).

While the political polarisation of this pandemic poses a problem for implementing a vaccine programme that people will accept, there may be ways to optimise employee acceptance of a vaccine. For example, while nearly 72% of the non-vaccinated respondents in this study reported concerns about potential vaccine side effects as a reason for hesitancy, polling from Hamel et al (2021b) suggests that employees were more likely to report receiving a vaccine if they received encouragement from their employer and/or received paid sick leave to recover from side effects. This is an example of a simple, cohesive solution that can be implemented across EMS agencies as a strategy to combat a key concern while empowering EMS professionals to elect to receive a vaccine without fear of consequence. Further research is needed to identify the best strategies for deploying a successful vaccine acceptance programme.

Limitations

There are some limitations to note in this study. Data were collected using convenience sampling and the results may not necessarily be generalisable to all EMS professionals.

Additionally, this study was conducted during a time when vaccines had been available for a brief period during a dynamic pandemic. It is possible that, as new information is produced regarding the vaccines' long-term safety and efficacy, participants who have deferred the vaccine may change their opinion.

Further study is needed to fully explore the intrinsic and extrinsic psychological motivations of vaccine acceptance and avoidance.

Conclusion

As EMS health professionals' age, level of education and level of certification increase, they are more likely to receive the COVID-19 vaccine. Practitioners' personal and clinical experiences are also statistically significant predictors of vaccination acceptance.

Respondents who have not received a vaccine report that they are unlikely to accept one in the future. Unvaccinated participants cite scepticism over its safety and efficacy, and a distrust of information reported by the CDC/government as reasons for vaccine hesitancy.

Further research is needed to identify best practices to promote vaccine acceptance and overcome vaccine hesitancy among EMS professionals.

Key points

CPD Reflection Questions