INTRODUCTION

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, 2020b, 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.

METHODS

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

Design

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.

Research team and reflexivity

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.

Setting and time

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

Sample

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).

Measures

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). It consisted of questions about the socio-demographic characteristics of the healthcare workers, such as age, gender, and educational status and also about their attitudes toward the COVID-19 pandemic. The semistructured interview consisted of three open-ended questions: (1) As a healthcare worker, what do you think about the COVID-19 vaccinations? (2) How do you feel about healthcare workers being the first to be vaccinated against COVID-19? (3) As a healthcare worker, what attitude do you have toward the vaccine administration?

Data collection method

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.

Analysis of study data

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).

TABLE 1. Colaizzi's method of data analysis

Transcripts were read several times and short notes were taken. Thus, the meaning and emotion of the phenomenon were understood.

The important statements were chosen.

Important statements with common meanings were rendered systematic.

The systematic subthemes were organized by themes and categories.

The results obtained were combined with the life experiences of the individuals.

The basic conceptual structure of the phenomenon was determined.

The results were confirmed to accurately represent the experiences of healthcare workers.

Ethical aspects of study

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

Trustworthiness

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.

RESULTS

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.

Part 1. Individual demographics of the healthcare workers

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.

TABLE 2. Individual characteristics of the healthcare workers (N = 36) Variables n % Min–Max Mean ± SD Age 21–53 34 ± 19 Gender Female 12 33.3 Male 24 66.7 Marital status Married 15 58.3 Single 21 41.7 Educational status High school 3 8.1 Bachelor's degree 16 43.2 Master's degree 7 18.9 Doctoral degree 10 27.8 Do you have kids? Yes 17 47.2 No 19 52.8 The number of people whom you live with at the same house. 0–9 3.03 ± 1.84 Do you have a chronic disease? No 29 80.6 Yes 7 19.4 Chronic disease (n: 7) Diabetes 1 2.8 Hypertension 2 5.6 Other 4 11.1 Profession Physician 7 19.4 Nurse 11 30.6 Dentist 3 8.3 Medical secretary 2 5.6 Clinical psychologist 3 8.3 Midwife 6 16.7 Laboratory assistant 1 2.8 Cleaning staff 1 2.8 Physiotherapist 2 5.6 The institution where you work State hospital 19 52.8 Private hospital 4 11.1 University Hospital 5 13.9 Other 8 22.2 Duration of working in the profession (years) 1–30 11.31 ± 7.95 Duration of providing care to patients diagnosed with the COVID-19 (months) 1–24 4.25 ± 5.73 The unit where you worked while providing care to patients diagnosed with the COVID-19? Emergency service 2 5.6 Surgical units 8 22.2 COVID-19 service 1 2.8 Covid-19 intensive care unit 2 5.6 Internal units 2 5.6 Filiation 5 13.9 Outpatient clinic 2 5.6 Other 14 38.9 Have you been diagnosed with the COVID-19? Yes 8 22.2 No 28 77.8 Has any of your relatives been diagnosed with the COVID-19? Yes 33 91.7 No 3 8.3 Were you able to go home while providing care to the COVID-19 patients? Yes 34 94.4 No 2 5.6 Part 2. Categories, subthemes, and themes obtained from interviews with healthcare workers

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.

Theme 1. Influencing factors

The theme of “influencing factors” contained five subthemes, including “negative emotions,” “social media,” “vaccine and vaccination process,” “political processes,” and “intention to be vaccinated.”

Negative emotions

Some participants emphasized that they felt anxiety, fear, suspicion, burnout, vulnerability, insecurity, hopelessness, and helplessness, and that these feelings affected their opinion about the vaccine. Below, are some of their statements:

“I am worried about the contraindications of the vaccine, I do not know what results it will create.” (Healthcare Worker 20, Female)

“I think we”re in a biological war. This is a product produced in a laboratory environment… I prefer not to be vaccinated.” (Healthcare Worker 28, Female)

“ …I do not know whether it causes any disease or deformation. I feel helpless and scared” (Healthcare Worker 24, Female)

“I cannot persuade myself to get vaccinated, I am a little paranoid about it. I do not trust it” (Healthcare Worker 27, Female)

“I have no hope for the effectiveness of the vaccine so I feel very helpless and vulnerable.” (Healthcare Worker 28, Female)

“Given our psychological state, I need more time off and more rest than vaccination. I need to see my family more even if it is for two days. Yes, I also need vaccines, but I think they are doing it just to say that we are doing something for healthcare workers too, not because they are worried about us.” (Healthcare Worker 3, Female)

Vaccine and vaccination process

Some participants reported that they did not want to be vaccinated due to the vaccine's reported contraindications and uncertainties about the duration of protection, the benefit–harm balance, myths, and confusion. However, they were left in a dilemma because of institutional pressures and the possibility of dismissal. Participants also noted that no medical history was taken before vaccination and no observations were performed after it.

“The explanations made and the evidence shown about the benefits, harms and effect of the vaccine are insufficient, so I am very confused about whether to be vaccinated or not, I can't be sure.” (Healthcare Worker 10, Male)

“Recently, it has often been said that the COVID-19 vaccine causes infertility. I don't want to be vaccinated when I hear them.” (Healthcare Worker 9, Female)

“….the possibility of removal from the profession is being discussed. Last week, it was reported in a country that sanctions such as removal from the profession were imposed on those who did not want to get vaccinated. It is believed that the same situation may be seen in Turkey.” (Healthcare Worker 5, Male)

“I wonder whether there will be certain prohibitions or sanctions for those who do not get vaccinated.” (Healthcare Worker 25, Female)

“While the vaccine is being administered, you are not asked the questions such as “do you have any illnesses, or do you have any allergies to any drug?”. They directly inject the vaccine and send you back. There is no observation. It seemed strange to me.” (Healthcare Worker 22, Male)

Social media

Participants mentioned that statements from the Ministry of Health and images on social media of healthcare workers being vaccinated had positive impacts on their opinions about vaccination.

“Watching the Minister of Health's statements and the footage of him being vaccinated gave me confidence.” (Healthcare Worker 23, Female)

“I think the fact that healthcare workers share images of vaccination on social media increases the community's trust in vaccination. I felt excited when I saw the images.” (Healthcare Worker 35, Male)

Political processes

Some participants reported feelings of bias toward the country in which the vaccine was developed. They considered the vaccine a commercial tool and preferred to wait for the production of a domestic vaccine. Moreover, some participants stressed that statistics about the safety and protection of the vaccine, as well as the case rate and number of deaths from COVID-19, were not identified correctly or shared transparently. They thought this was for political reasons, and that the main goal of national policy was to increase Turkey's vaccination ranking.

“Now we have a vaccine produced by China. I'm afraid I have some prejudices about it. For example, it might have been better if it had been a vaccine produced in Germany.” (Healthcare Worker 2, Male)

”In this process, I think the vaccine has become a commercial tool between countries.” (Healthcare Worker 8, Male)

“I prefer to be vaccinated with a domestic vaccine. So I'll wait for production of a domestic vaccine.” (Healthcare Worker 30, Female)

“The only thing that cannot convince me and that raises a question in my mind is the political aspect of this business. The state of health was politicized, the Ministry did not give the correct rates. From the number of patients to the number of deaths, from the introduction of the vaccine to the transport company… What is the rate of protection in other countries, what are the results? All of these leave a question mark in my head.” (Healthcare Worker 31, Female)

Theme 2. Priority group

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

Attitude

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.

“It's definitely the right decision. I am happy that healthcare workers are vaccinated first because the quantity of vaccines is limited.” (Healthcare Worker 30, Female)

"I certainly didn't find this decision right. That is because if the contraindications of the vaccine are severe, there will be no soldiers left to fight on the front.” (Healthcare Worker 19, Male)

"The fact that the COVID-19 vaccine is administered first to the healthcare workers serves advertisement purposes, I think.” (Healthcare Worker 31, Female)

“They tell us to get vaccinated first as healthcare workers, and then they want to be vaccinated, and I feel like a subject" (Healthcare Worker 11, Female)

“They're actually using us like guinea pigs, and trying to create a perception of ”Look, doctors and nurses have been vaccinated” and lead society to be vaccinated." (Healthcare Worker 5, Male)

Intention to be vaccinated

Some participants mentioned that protection of family and society, prevention of loss of life and ending of the pandemic all depended on the vaccine, so they were placing their trust in the vaccine and wanted to be vaccinated.

“We have no other choice, and we have to consider the profit and loss status for ending this pandemic.” (Healthcare Worker 34, Male)

“I live with my family, and I want to protect them. So I'll get vaccinated.” (Healthcare Worker 21, Female)

Theme 3. Trust

Participants reported that they expected the vaccine to provide a high level of protection. They said they would place their trust in the vaccine when certain expectations were met: the Ministry of Health should offer different vaccine options, improve the appointment and notification system, present evidence-based information about the vaccine, and establish a safe environment.

“I'm thinking why there is only one vaccine. There should be a few different options and we should be able to choose from them. If that were the case, my trust would be a little higher.” (Healthcare Worker 11, Female)

“If the Ministry of Health improves the app