This study looks at vaccine hesitancy and motivations among EMS personnel to help future vaccination efforts.
Objective: The COVID-19 pandemic has been an extraordinarily challenging period. High-acuity patients, shortages of personal protective equipment, outbreaks within emergency medical service (EMS) agencies and uncertainty about the future have led to significant stress. The approval of effective vaccines had the potential to ameliorate these concerns. However, significant hesitancy among EMS and the public regarding the vaccines had the potential to limit the effectiveness of public health efforts to reduce SARS-COV2 transmission. The goal of our study was to explore vaccine hesitancy and motivations among EMS personnel to inform ongoing and future vaccination efforts.
Method: We conducted a survey of 27 EMS agencies in Connecticut, comprising 337 paramedics and 1,150 EMTs. The survey was distributed anonymously via email using unique identifiers to ensure no duplicate responses. Clinicians were asked their vaccination status, demographic questions and their primary motivators both for and against vaccination.
Results: A total of 250 EMS clinicians responded to our survey including 103 paramedics, 137 EMTs, and 10 EMRs. Over half (52%) were employed at fire-based services, 35% were employed by private agencies, and 6% by municipal third services. Most (76%) respondents were male, 88% were Caucasian, and 65% were between the ages of 20 and 40. Political affiliation included 34% Republican, 25% Independent, and 20% Democrat. 84.8% reported receiving a full vaccination series against COVID-19.
The most common motivators for vaccination in this group in descending order were: protect my family, protect myself, protect my coworkers, protect my patients. Social pressure, both from coworkers and from employers, was ranked low as a motivator. The most common deterrents against vaccination were: fear of long-term consequences, safety concerns, a sense that the vaccine was rushed, fear of side effects and concern about lack of benefit. 20% reported changing their minds about vaccination at some point during the rollout process.
Conclusions: These preliminary data suggest that vaccination rates among EMS professionals in our system are high and modestly exceed statewide vaccination rates. Primary motivators for vaccination were centered around a desire to protect one’s family, self, coworkers and patients. Primary hesitancy was centered around safety and efficacy concerns. Communities that face lower vaccination rates among EMS personnel should consider outreach efforts that emphasize these motivational factors and provide data to alleviate the safety and efficacy concerns.
On December 11, 2020, Pfizer was granted an Emergency Use Authorization by the U.S. Food and Drug Administration for its mRNA vaccine against SARS-CoV-2.5 Since then, Moderna and Johnson & Johnson have followed suit and obtained approval for their vaccines.6,7 These three vaccines have proven to be safe and highly effective against SARS-CoV-2.8-10 However, significant vaccine hesitancy has hampered the vaccination rollout and as of August 2nd, 2021, only 49.6% of the US population is fully vaccinated.11 There has also been media coverage of low rates among some first responder groups. A recent NY Daily News article revealed that vaccination rates among the FDNY’s 17,000 members was only 54%.12
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Previous studies have explored factors leading to vaccination hesitancy among the general population.13-35 There have also been investigations into hesitancy among health care workers as well as potential solutions to increase motivation.36-46 However, little is known about vaccination hesitancy among prehospital clinicians including emergency medical responders (EMRs), emergency medical technicians (EMTs), and paramedics. Of the few studies that do exist, most were performed before the Emergency Use Authorization and explored willingness to get vaccinated once approved and available. Little is known of vaccination rates after the rollout. In most states, first responders were offered vaccinations during Tier 1A of the federal government’s vaccine rollout, along with other health care providers.47 However, despite recommendations from national EMS organizations urging vaccination,48,49 significant hesitancy seems to exist among EMS clinicians.37 Vaccination among EMS is critically important, as EMS clinicians perform essential front-line roles. The health of the workforce, as well as limited absenteeism, is important to ensure public safety. Further, EMS has frequent contacts with older and vulnerable populations and could potentially be a mode of transmission to these at-risk groups.
The primary objective of our study was to explore vaccination hesitancy and motivations among EMS clinicians in our health care system. We sought to benchmark vaccination rates as well as prioritize known motivators both for and against vaccination. Our hope is that understanding these decision motivations could inform ongoing and future vaccination efforts.
The survey was developed by a core team of three emergency physicians, two of whom are subspecialty board certified in EMS, in collaboration with an expert in survey science, a data analyst, and an epidemiologist. This team reviewed existing published surveys and other articles on the topic of vaccination hesitancy to inform survey development. The survey was then pilot-tested by an additional group of two physicians and a physician associate actively involved in EMS. Another round of edits was made prior to dissemination.
The survey consisted of a 14-question instrument that asked respondents demographic questions including age, sex, race, political party affiliation, type of employer, level of EMS training and whether the person had ever tested positive for SARS-CoV-2. Respondents were then queried on their current vaccination status. They were also asked about specific motivators and hesitancies towards vaccination. Clinicians were asked to rank their primary hesitancies and motivations for vaccination in order from 1 to 7 (1 being strongest, 7 being weakest). Free text options were provided as well. Clinicians were also asked if they ever changed their mind regarding vaccination and if so, what prompted this change.
This survey was distributed to all EMS clinicians in our system, which includes 27 EMS agencies comprising 337 paramedics and 1,150 EMTs. Our agencies include a mix of service models including private, fire-based, municipal third service and volunteer.
Qualtrics XM was used to distribute the survey anonymously via email to all participants. Qualtrics XM is a secure, password-protected data collection tool. Surveys were collected electronically and anonymously. Responses were filtered by IP address to prevent duplicate responses. Non-responders received follow-up emails to encourage a response.
Data were exported into Microsoft Excel for analysis. Simple descriptive statistics were used to summarize the data. Word Clouds were created using the “R” statistical software.
This study was reviewed by Yale University’s institutional review board and granted an exemption under federal regulation 45 CFR 46.101(b)(2).
We received responses from 250 EMS clinicians including 103 paramedics, 137 EMTs, and 10 EMRs, for an overall response rate of 17.9%. Response rates differed by level of training and were higher among paramedics (30%) than among EMTs (14.4%).
Demographics are detailed in Table 1.
|Other/prefer not to say||1||0.4%|
|American Indian/Alaska Native||0||0.0%|
|Black or African American||6||2.4%|
|Hispanic or Latino||19||7.6%|
|Native Hawaiian or Other Pacific Islander||1||0.4%|
|Type of agency|
|Prefer not to answer||29||11.6%|
|How many doses of vaccine did you receive?|
|Tested positive for COVID?|
Multiple EMS delivery models were represented in this sample including 35% of respondents from a private agency, 52% from a fire service, and 6% from a municipal third service. 76% of respondents were male, 88% were Caucasian, and 65% were between the ages of 20 and 40. Political affiliation was varied, and included 34% Republican, 25% Independent, and 20% Democrat. 84.8% of survey respondents reported receiving a full vaccination series against COVID-19.
Box-and-whisker plots were used to visually display rankings for factors related to vaccine hesitancy and motivators (Figures 1-2).
Respondents ranked each motivator/hesitancy factor from strongest to weakest, with lower numbers indicating more important motivators/hesitancies and high numbers indicating lower importance. The box-and-whisker plots show the variation in rankings that respondents gave for each motivation/ hesitancy.
Other factors related to vaccine hesitancy from the free-text box are detailed in Figure 3.
Hesitancy centered primarily around safety and efficacy concerns. Respondents expressed concern that there was insufficient knowledge of long-term safety and side-effects. They also expressed concerns that the vaccine was rushed.
Motivative factors for vaccination from the free-text response field are detailed in Figure 4.
The most common motivators centered around protection of one’s family, oneself, one’s coworkers and patients. Social pressure as a motivator was ranked low and did not appear to be a major factor for most respondents.
Twenty percent of respondents reported changing their minds about vaccination at some point during the rollout process. Responses related to factors driving this change were free-text and varied, but many centered around further evidence of safety and efficacy, as well as concerns regarding the safety of their families. These are demonstrated in Figure 5.
The Word Clouds are seen in Figures 3-5. They provide a visual aid to demonstrate the most common themes identified by our survey in the free text responses. We include both individual words and bigrams (two-word phrases like “side effects”). The size of the words is increasing with the frequency the word or phrase was mentioned in the responses. They highlight concerns such as already testing positive or having antibodies as hesitations. They also demonstrate key themes for motivators. Words such as “normal,” “get back,” “travel,” and “masks” give a perspective that likely would not be conveyed by simple discrete survey items but demonstrate the desire for a return to pre-pandemic normalcy as a main motivator for those who obtained the vaccine. Family was the most cited reason that EMS clinicians selected as prompting them to change their mind, more important than research or travel.
Vaccine hesitancy remains a major challenge in the efforts to combat the SARS-CoV-2 outbreak. The recent emergence of the delta variant and the rising case numbers in the United States only serve to highlight the need to understand hesitations in order to increase the likelihood of successful vaccination efforts both currently and in the future. Our study found a relatively high vaccination rate among our EMS agencies with primary motivators being protecting family, oneself, coworkers, and patients. Primary hesitancies centered around safety and efficacy concerns.
While there are many studies focusing on vaccine hesitancy among the lay public,13-35 less is known about health care workers. Many of the studies available were performed before the Emergency Use Authorization. They also tend to be limited by low response rates, as was our study. Many of the studies show varied willingness to accept vaccination. Li et al. performed a systematic review of 13 studies looking at health care worker willingness to obtain vaccination against SARS CoV-2. They found that acceptance rates varied widely, from 27.7% to 77.3%. They also found that males, physicians, and older participants were more likely to be vaccinated.41 Primary concerns identified by respondents focused on safety and efficacy.41 Concerns cited in other studies include feared side effects, infertility and pregnancy-related concerns.36,40 The perceived rushed process for vaccination approval was also cited as a major point of hesitation.42 Several studies also identified race as a predictor of vaccine acceptance, with African Americans consistently being the least likely to accept vaccination.38,40 Our study also identified many of these same concerns, particularly regarding safety and efficacy of the vaccine. However, our study did not look at race a predictor.
While the data on health care workers in general are somewhat limited, even less is known
regarding vaccine hesitancy as it pertains to EMS clinicians. The only available US-based study on EMS clinicians was performed by Caban-Martinez et al. They conducted an anonymous survey of firefighters and EMS clinicians to assess vaccine acceptability rates. This was performed before the vaccines were approved by the Food and Drug Administration. They were unable to calculate a response rate because professional organizations were asked to forward the survey, which significantly limits their results. They found significant reluctance to obtain vaccination, with only 48.2% expressing high acceptability of the COVID-19 vaccine when it becomes available. 24.2% of respondents were unsure and 27.6% reported low acceptability.37 The only other EMS study identified in our literature search is by Nohl et al. in Germany. Their study was also performed before the vaccines were widely available in Germany, which limits the generalizability of their results. They performed a web-based survey of EMS clinicians. The found that only 57% of their respondents were willing to be vaccinated. Vaccination acceptance rates were higher among the males, higher educated respondents, and older age respondents.43
Our results are consistent with much of the published literature in terms of primary motivators and hesitancy. Our respondents regularly cited concerns regarding safety, efficacy, and a perceived expedited review process as their major hesitation to obtaining vaccination. They cited protection of their family, themselves, their coworkers, and their patients are their primary motivators for vaccination. This is particularly important because it has the potential to impact educational campaigns and vaccination rollouts in the future. Our data suggests that social pressure is not a major motivator among EMS personnel and is unlikely to be effective at improving vaccination rates. Rather, it suggests that effective vaccination interventions aimed at increasing rates should highlight benefits to clinicians’ families, colleagues and patients. It also suggests that educational campaigns should focus heavily on addressing concerns regarding the safety and efficacy of the vaccine.
Our vaccination rate is quite high among respondents at 86%. While this may be due to selection bias, a similar study by Roy et al. (also done at our institution but among hospital staff rather than prehospital clinicians) found very similar acceptance rates. They found that 85% of respondents stated they were extremely likely or somewhat likely to receive the COVID-19 vaccine.45 Additionally, the six-month healthcare worker vaccination rates at our institution approach this estimate which was obtained at the time of the Emergency Use Authorization. Importantly, no agencies in our system currently mandate vaccination, but significant outreach from the EMS medical direction team focused on providing evidence of safety and efficacy of the vaccines and encouraging vaccination.
This study has several limitations. First, survey studies have inherent limitations including inflexibility in response and validity challenges. We attempted to correct for some of these limitations by allowing free text and incorporating these into Word Clouds to convey the overall sentiments of our respondents. Notably, we opted not to use skip logic for the questions related to primary hesitancy and motivations based on vaccine status as we felt that the response would be instructive regardless of final vaccination decision. Likely as a result, the words “already” and “vaccinated” are prominent in the Word Cloud.
Second, in order to preserve anonymity of respondents, an anonymous survey was used and distributed via email. This led to inherent difficulties as nearly 10% of emails bounced back and we were unable to confirm how many were opened, ended up in spam folders, etc. Engagement also appeared to be low and as a result, our overall response rate was low at 17.9%. This likely limits the generalizability of our results.
Third, our study was conducted in a single EMS system. Although we have many different types of agencies and levels of training, from a demographics standpoint our EMS clinicians are predominantly male and Caucasian. While this may also be true for most EMS systems in the United States, it also has the potential to bias the results.
Lastly, our vaccination rate in this study is high at 86%. This may be reflective of a high rate in our system as a whole as Connecticut has the fourth-highest vaccination rate in the United States, or it may be due to selection bias. Regardless, it potentially limits the generalizability of our findings.
Our findings suggest that vaccination rates among EMS professionals in our system are high. Vaccine hesitancy remains an issue, and primary concerns identified center around questions of the efficacy of the vaccine as well as its safety. Primary motivators to obtain vaccination for EMS clinicians were centered around a desire to protect one’s family, self, coworkers and patients.
Efforts to encourage vaccination in the future should focus on the motivators and hesitancies identified in order to potentially obtain higher vaccination rates among EMS clinicians. Further research should also evaluate specific interventions targeting the high priority motivators and hesitancies.
IRB approval was obtained for this study.
The authors have no conflicts of interest to report.
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