Healthcare workers (HCWs) have and will continue to be central to the success of any vaccination programme because they are trained and tasked to administer vaccination injections and to work in the health system, which is the custodian of any national vaccination programme. In the recent case of the coronavirus disease 2019 (COVID-19) pandemic, their role became critical, not only for the administration of COVID-19 vaccines, but also as they were expected to play a role in increasing vaccine uptake rates by advocating for vaccination to patients and others with whom they interacted.1–5 Well before the COVID-19 pandemic, research had already established a strong relationship between HCW attitudes, their personal vaccine behaviour, and their willingness to recommend vaccines to patients.6

Low vaccination rates among HCWs and high levels of vaccine hesitancy can have a ripple effect, resulting in decreased vaccination uptake among those who engage with HCWs at professional and personal levels.7 Conversely, research suggests that HCWs who are vaccinated exhibit positive attitudes towards vaccines, making them ideal advocates or vaccine ambassadors.8–10 HCWs can increase vaccine confidence among patients by providing information and through effective communication. However, this reflects an inherent expectation that HCWs are knowledgeable about the potential risks and benefits of vaccinating against COVID-19, and that they possess the skills and confidence to communicate this to patients, which is not always the case.11,12 Furthermore, in cases where HCWs are themselves hesitant to be vaccinated, they are likely to transmit their concerns and doubts about vaccination to their patients and the broader community.6,11 Research has highlighted that HCWs may share some of the same questions and concerns as the general public regarding vaccination.13,14

Previous public health events of the 21st century – including outbreaks of the Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome, influenza A, and Ebola virus disease – have shown that risk communication and community engagement are integral to successfully responding to public health emergencies.15 As a trusted source of information, HCWs typically act as a conduit for information, and they are largely tasked with engaging with communities on matters related to public health.16 However, HCW communication practices regarding COVID-19 vaccines hinge on their confidence in the safety and the effectiveness of the vaccine, while other factors, including preference for physiological immunity through natural infection, distrust in government and pharmaceutical companies, and an emphasis on autonomy and personal freedom, may affect both their own vaccination choices and the recommendations they make to patients.17,18 Additionally, hesitancy and reluctance to promote vaccination to patients may also be fuelled by a combination of ignorance, misinformation, conspiracy theories, doubt about scientific evidence, concerns relating to medical histories, and cultural, religious and philosophical beliefs.6,19

In the South African context, there are reports that some HCWs, including doctors, have actively discouraged patients from getting COVID-19 vaccinations.20 While this evidence is largely anecdotal, it remains cause for concern, and could be a factor in the country’s stubbornly slow vaccine and booster uptake rates.21 Based on this premise, the present study aimed to explore HCW willingness to promote COVID-19 vaccines to family, friends and patients and how this correlated with selected demographic characteristics, their own vaccination or alternative therapeutic behaviour, and whether they had sufficient information and adequate skills with which to engage patients on COVID-19 vaccines. The study further qualitatively explored both the content and nature of these interactions, expanding on what were limited insights into HCW interactions with patients around COVID-19 preventive and treatment options. The findings are relevant, not only in the context of the COVID-19 vaccination programme in South Africa, which has largely been scaled back (at time of writing), but for vaccination programmes more broadly, in which the role of HCWs will continue to remain both central and critical to an effective public health response.


This study was part of a larger mixed methods study conducted between the 18th of July and the 28th of October 2022, that aimed to investigate reasons for HCW vaccine acceptance and hesitancy in South Africa. Details of the larger study are available elsewhere.22 Data for this study were drawn from a web-based quantitative survey which explored HCW beliefs and attitudes about vaccines, perspectives on patients being vaccinated, views and use of complementary and alternative medicine for COVID-19, and patient-targeted communication. These data were augmented by qualitative data collected through a series of virtual online in-depth interviews (IDIs) with participants who completed the survey and indicated willingness to participate. The Foundation for Professional Development’s (FPD) database was used to recruit HCWs. The FPD is a private higher-education institution that provides training to HCWs, and with permission, records their details in the database. All HCWs who were part of the FPD database were invited through email and social media platforms to participate in the survey, and all the study participants were self-declared HCWs. A total of 7 763 HCWs participated in the full survey. Only study participants randomised22 to answer the two sections (Sections 4 and 5) containing questions on HCW willingness to promote vaccines to patients, and participants who were in direct contact with patients, were included in the final analysis, which included a total of 2 011 participants.

The survey was divided into two parts. The first part included demographic information and data on vaccination behaviour, and was completed by all participants. The second part was divided into five sections. Participants were randomly assigned to complete one of the five sections to decrease the time it would take them to complete the survey and to ensure high response rates and better data quality. The full study design, along with recruitment and data-collection details, has been described elsewhere.22 This chapter presents analyses using variables from two of these sections focusing on HCW willingness to promote vaccines to friends, family and patients.

Section 1 explored factors influencing vaccination decision and general attitudes towards vaccination. Section 2 covered perceived COVID-19 vaccine benefits, both specific and general. Section 3 included questions on perceived vaccine safety, efficacy and perceived risk. The present chapter reports on HCW willingness to promote vaccines to friends, family and patients, which was only asked in Sections 4 and 5. Additionally, Section 4 included questions on COVID-19 vaccine information among HCWs and skills to enable engagement with patients. Section 5 included questions on using and recommending alternative medicines for prevention and/or treatment of COVID-19 including: “Have you used alternative medicines for prevention and/or treatment of COVID-19?” and “Have you recommended alternative medicines for prevention and/or treatment of COVID-19?”

The primary outcome measure was a binary variable for whether or not participants would recommend vaccination. Two survey items were used to create the outcome variable.23 The first item was from Section 4. Participants were asked to indicate the degree to which they agreed with the following statement: “I would not recommend the COVID-19 vaccine to my patients, family, and friends because I am concerned about the safety of the vaccine”. Responses were given on a four-point Likert scale: ‘strongly disagree’, ‘disagree’, ‘agree’, and ‘strongly agree’. ‘Strongly disagree’ and ‘disagree’ were combined as ‘recommend’, while ‘agree’ and ‘strongly agree’ were combined as ‘not recommend’. The second item was from Section 5 of the survey. Participants were asked: “Would you recommend COVID-19 vaccination to eligible patients?” This was captured as ‘no’, ‘yes’, and ‘unsure’. Responses given as ‘no’ and ‘unsure’ were combined as ‘not recommend’, while ‘yes’ was ‘recommend’.

A binary variable was created for composite COVID-19 vaccine knowledge.23 Participants were asked five questions about their COVID-19 vaccine knowledge: “Do you have enough information about how COVID-19 vaccines work?”, “Do you have enough information about how effective COVID-19 vaccines are?”, “Do you have enough information about how safe COVID-19 vaccines are?”, “Do you have enough information about COVID-19 vaccines’ side-effects?”, and “Do you have enough information about how to use COVID-19 vaccines?” All questions were captured as ‘no’, ‘yes’, or ‘unsure’. Responses given as ‘no’ and ‘unsure’ were combined as ‘not enough information’, while ‘yes’ was captured as ‘enough information’. These five questions were combined to form an independent variable, which was coded using a binary approach.

Three univariate logistical regression models were used to regress different measures against the same outcome variable. In the first model, the outcome variable was regressed against demographic characteristics. In the second model, the outcome variable was regressed against vaccination status and against using and recommending alternative medicines for prevention and/or treatment of COVID-19. In the third model, the outcome variable was regressed against vaccination status and COVID-19 vaccine knowledge and perspectives. In every model, the aim was to determine how significantly each measure influenced whether a participant recommended vaccination or not.

In addition, one multivariate logistical regression model regressed the outcome variable against the measures that emerged as significant in the third model, namely vaccination status and COVID-19 vaccine knowledge. Control variables in the model were age, gender, race, religion, nationality, chronic conditions, occupation, health sector, facility, and years worked.

Qualitative data were collected to further elucidate perspectives on HCW COVID-19 vaccine behaviours and patient interaction. As part of the survey, participants had the option to indicate their willingness to be contacted for a follow-up interview. Random selection was done among those who indicated such willingness, using the ‘randbetween’ formula in Microsoft Excel for IDIs by vaccination status. Participants were then contacted, recruited, and interviews were done with 10 vaccinated and 20 unvaccinated interviewees. Interviews were conducted by two authors (PBN and GG), both experienced researchers with a background in conducting qualitative research and using interview guides. Two interview guides were developed (one for vaccinated and another for unvaccinated HCWs) with open-ended questions and probes on the following: (i) vaccination behaviour; (ii) experiences with administering vaccines; (iii) perspectives on the national vaccine programme; (iv) the vaccines and how HCWs gather and appraise information sources; and (v) perspectives on educational resources that can be used to support HCWs. The virtual IDIs were conducted on Zoom and were 30-45 minutes in duration. The Zoom transcribing software was used to transcribe the recorded interviews. The transcripts were reviewed and edited by two research interns and one author (PBN) to eliminate typographical errors, and saved on Microsoft Word (version 16.70). Qualitative data were analysed thematically using an inductive approach as prescribed by Braun and Clarke.24 The qualitative data were then triangulated with the quantitative data to gain deeper insight into HCW experiences with COVID-19 vaccines and patient engagement.


Table 1 shows the demographic characteristics of the sample. As evident in the table, most of the sample was younger than 35 years old (31.4%), and 35-49 years old (42.0%). More than half the sample was female (71.1%), identified as black (55.1%) and South African (92.5%). The majority of the sample did not have a chronic condition (65.7%). The main occupation in the sample was nurse (45.7%), with doctors comprising 22.4% of the sample. Participants were mostly working in the public (43.9%) or private (36.6%) health sectors, and in hospitals (46.4%) and clinics (34.1%). Most of the sample had worked for 10 or more years (62.3%). Most of the sample were vaccinated (90.7%) and would recommend vaccination (81.7%).

Table 1.Demographic characteristics of the study sample
Measures n %
Age (n=2 005) Younger than 35 years old 629 31.4
35-49 years old 842 42.0
50 years old or older 534 26.6
Gender (n=1 996) Male 577 28.9
Female 1 419 71.1
Race (n=1 961) Black 1 081 55.1
Coloured 138 7.04
Indian 119 6.07
White 623 31.8
Religion (n=1 945) Christian 1 613 82.9
Muslim 86 4.4
Buddhist or Hindu 68 3.5
African Spirituality 53 2.7
Other 125 6.4
Nationality (n=1 982) South African 1 834 92.5
Non-South African 148 7.5
Chronic conditionsa (n=2 010) No 1 320 65.7
Yes 690 34.3
Occupation (n=2 011) Nurse 919 45.7
Doctor 451 22.4
All otherb 641 31.9
Health sector (n=2 010) Public 868 43.2
Private 735 36.6
NGO 161 8.0
Public and Private 182 9.1
Other 64 3.2
Facility (n=2 010) Hospital 933 46.4
Clinic 685 34.1
Residential aged or disability care 41 2.0
Other 351 17.5
Years worked (n=2 009) Less than 5 292 14.5
5 to 9 466 23.2
10 or more 1 251 62.3
Vaccinated (n=1 975) No 183 9.3
Yes 1 792 90.7
Would recommend vaccination (n=1 914) No 351 18.3
Yes 1 563 81.7

a Chronic conditions were defined as one or more of the following: diabetes, hypertension, respiratory disease, HIV, or other chronic diseases.
b This category included pharmacists, allied health professionals, personal service workers, paramedics, other health professionals, and other.

Table 2 presents the study’s COVID-19 vaccine measures of interest. As seen in the table, 39.1% of participants had used alternative medication, with a similar proportion (35.1%) recommending alternative medication to patients. Vitamins and dietary supplements were the main alternative treatments used (57.3%) and recommended (54.1%). Most of the sample indicated that they would encourage pregnant women (62.7%) and children over the age of 12 years (74.4%) to get vaccinated. More than half the sample (58.6%) felt that they did not have enough information on COVID-19 vaccines, and 59.8% reported needing guidance on how to educate their patients about COVID-19 and the available vaccines.

Table 2.COVID-19 vaccine measures of interest
Measures n %
Has used alternative medicines for prevention and/or treatment of COVID-19 (n=980) No 597 60.9
Yes 383 39.1
Alternative medicines used (n=382) African traditional 73 19.1
Vitamins/dietary supplements 219 57.3
Othera 90 23.6
Has recommended alternative medicines for prevention and/or treatment COVID-19 (n=979) No 635 64.9
Yes 344 35.1
Alternative medicines recommended (n=344) African traditional 70 20.4
Vitamins/dietary supplements 186 54.1
Otherb 88 25.6
Would encourage pregnant women to get vaccinated (n=957) No 357 37.3
Yes 600 62.7
Would encourage children over the age of 12 years to get vaccinated (n=956) No 245 25.6
Yes 711 74.4
Has enough information about COVID-19 vaccinesc (n=958) No 561 58.6
Yes 397 41.4
Needs guidance on how to educate patients about COVID-19 and the available vaccines (n=956) No 384 40.2
Yes 572 59.8

a This category included Chinese herbal medicine (2.1%), Western herbal medicine (7.1%), Ivermectin (10.5%), Chloroquine (1.1%), and other (2.9%).
b This category included Chinese herbal medicine (1.5%), Western herbal medicine (7.6%), Ivermectin (11.1%), Chloroquine (1.7%), and other (3.8%).
c The way this summary variable was generated is described in the Methods section.

Table 3 presents the univariate analysis of the sample’s demographic characteristics. As reflected, white HCWs were less likely to recommend vaccination than black HCWs (OR=0.58 [95% CI: 0.45 - 0.75]). In addition, all other HCWs such as pharmacists, allied health professionals, personal service workers, paramedics, and other health professionals were less likely to recommend vaccination than nurse HCWs (OR=0.46 [95% CI: 0.35 - 0.60]). Other facilities, including general practitioner practices, were less likely to recommend vaccination than hospitals (OR=0.62 [95% CI: 0.45 – 0.83]).

Table 3.Univariate analysis on the demographic characteristics of the study sample
Measures Recommend n (%) Odds ratio [95% CI]a
Age Younger than 35 years old 486 (81.3%) 1.00
35-49 years old 667 (82.8%) 1.10 [0.84 - 1.45]
50 years old or older 409 (80.8%) 0.97 [0.71 - 1.31]
Gender Male 441 (79.3%) 1.00
Female 1 118 (82.9%) 1.26 [0.98 - 1.62]
Race Black 858 (85.0%) 1.00
Coloured 109 (82.0%) 0.80 [0.50 - 1.29]
Indian 98 (83.1%) 0.86 [0.52 - 1.44]
White 465 (76.9%) 0.58 [0.45 - 0.75]
Religion Christian 1 262 (82.5%) 1.00
Muslim 63 (73.3%) 0.58 [0.35 - 0.95]
Buddhist or Hindu 58 (85.3%) 1.23 [0.62 - 2.44]
African Spirituality 37 (77.1%) 0.71 [0.35 - 1.41]
Other 93 (76.9%) 0.70 [0.45 - 1.09]
Nationality South African 1 442 (82.5%) 1.00
Non-South African 110 (76.4%) 0.68 [0.45 - 1.03]
Chronic conditionsb No 1 035 (82.4%) 1.00
Yes 528 (80.4%) 0.87 [0.68 - 1.11]
Occupation Nurse 751 (86.2%) 1.00
Doctor 359 (82.5%) 0.75 [0.55 - 1.03]
All otherc 453 (74.5%) 0.46 [0.35 - 0.60]
Health sector Public 689 (84.0%) 1.00
Private 561 (79.5%) 0.74 [0.57 - 0.96]
NGO 131 (85.1%) 1.09 [0.67 - 1.76]
Public and Private 133 (76.9%) 0.63 [0.42 - 0.94]
Other 49 (81.7%) 0.85 [0.43 - 1.68]
Facility Hospital 792 (82.6%) 1.00
Clinic 554 (84.5%) 1.14 [0.87 – 1.50]
Residential aged or disability care 30 (75.0%) 0.63 [0.30 – 1.32]
Other 250 (74.6%) 0.62 [0.45 – 0.83]
Years worked Less than 5 223 (79.4%) 1.00
5-9 363 (82.3%) 1.21 [0.82 - 1.76]
10 or more 977 (82.0%) 1.18 [0.85 - 1.63]

a Univariate analysis, binary logistical regression.
b Chronic conditions were defined as one or more of the following: diabetes, hypertension, respiratory disease, HIV, or other chronic diseases.
c This category included pharmacists, allied health professionals, personal service workers, paramedics, other health professionals, and other.

Table 4 presents the univariate analysis of vaccination status, and the use of and/or recommendation of alternative medicines. As reflected in the table, vaccinated HCWs were more likely than their unvaccinated counterparts to recommend vaccination (OR=10.63 [95% CI: 6.53-17.31]). HCWs who had themselves used alternative medicines for prevention and/or treatment of COVID-19, were less likely to recommend vaccination than those who had not done so (OR=0.61 [95% CI: 0.43-0.86]). HCWs who had recommended alternative medicines for prevention and/or treatment of COVID-19 were less likely to recommend vaccination than those who had not made such recommendations (OR=0.69 [95% CI: 0.49-0.99]).

Table 4.Univariate analysis on recommending vaccination according the study’s COVID-19 vaccine measures of interest
Measures Recommend n (%) Odds ratio [95% CI]a
Vaccinated (Section 5 only) No 34 (42.0%) 1.00
Yes 785 (88.5%) 10.63 [6.53 - 17.31]
Has used alternative medicines for prevention and/or treatment of COVID-19 No 518 (86.78%) 1.00
Yes 307 (80.2%) 0.61 [0.43 - 0.86]
Has recommended alternative medicines for prevention and/or treatment of COVID-19 No 546 (86.0%) 1.00
Yes 279 (81.1%) 0.69 [0.49 - 0.99]

a Univariate analysis, binary logistical regression.

Table 5 presents the univariate and multivariate analysis on vaccination status, COVID-19 knowledge, and COVID-19 perspectives. As reflected in the table, vaccinated HCWs were more likely than their unvaccinated counterparts to recommend vaccination (OR=7.41 [95% CI: 4.57-12.01]). HCWs who felt they had enough information on COVID-19 vaccines were more likely to recommend vaccination than HCWs who felt insufficiently informed (OR=2.21 [95% CI: 1.57-3.11]).

Table 5.Univariate and multivariate analysis on HCW vaccination status and COVID-19 vaccine measures of interest
Measures Recommend n (%) Odds ratio [95% CI]a Odds ratio [95% CI]b
Vaccinated (Section 4 only) No 32 (40.0%) 1.00 1.00
Yes 697 (83.2%) 7.41 [4.57 - 12.01] 7.88 [4.59 - 13.53]
Has enough information about COVID-19 vaccinesc No 413 (73.6%) 1.00 1.00
Yes 342 (86.2%) 2.21 [1.57 - 3.11] 1.91 [1.27 - 2.86]
Needs guidance on how to educate patients about COVID-19 and the available vaccines No 303 (78.9%) 1.00 -
Yes 451 (78.9%) 0.99 [0.72 - 1.36] -

a Univariate analysis, binary logistical regression.
b Multivariate analysis, binary logistical regression.
c The way this summary variable was generated is described in the Method section.

Qualitative results

The qualitative results provide further insights into why most HCWs willingly administered and promoted vaccines, while others did so under duress or found it challenging as they felt inadequately supported to address concerns raised by patients. Further, the results draw attention to the use and promotion of alternative remedies among some HCWs. HCW narratives illustrate how personal beliefs, attitudes and perceptions influenced their engagement with patients on the subject of vaccines. Three themes emerged from the data: (i) HCW belief in the value of vaccines and their promotion strategies; (ii) challenges facing HCWs in administering and promoting COVID-19 vaccination; and (iii) the rationale for HCWs discouraging vaccination and promoting alternative medicine.

HCW belief in the value of vaccines and their promotion strategies

As confirmed in the quantitative data, the majority of HCWs were willing to recommend vaccination to family members and patients and felt comfortable addressing any concerns raised; this was the case among both vaccinated and unvaccinated HCWs. HCWs were at the coalface of this pandemic, observing high morbidity and mortality rates. Some perceived the availability of vaccines as having brought about a sea change – they observed a reduction in the number of cases, reduced severity of illness in vaccinated patients in relation to those who remained unvaccinated, and reduced mortality.

What I have experienced, and I have seen a number of people that we have vaccinated, I think the vaccine has given us immunity. I would say it has really improved in terms of people getting infected with COVID. The number of people who are vaccinated, they never experience it again. Even if maybe you could, it was just in terms of a mild flu … I think the vaccine is really effective. (P28, Nurse, female, vaccinated)

HCWs presented personal accounts of the perceived benefits of the vaccine.

My husband was sick, but I said to him after he had recovered "you would have been much worse, you probably would have ended up being on a ventilator [if you had not been vaccinated]", because he ended up having bronchitis, and I said to him “your bronchitis is related to long-term COVID”. And he now understands actually the benefits of having the vaccine. (P17, Nurse, female, unvaccinated)

HCWs trusted allopathic medicine and believed in the benefits of the available vaccines.

It’s an evidence-based field of medicine. Just like medicine itself, so yes. You know the evidence is there. You need the vaccine. (P11, Other HCW, female, vaccinated)

HCWs have historically seen the value of vaccination and applied the same principles to the available COVID-19 vaccines.

Personally, I think it is important. I think that again I’m a believer, so I have taken the flu vaccine annuallyI actually did promote the [COVID-19] vaccine, and quite actively. (P18, Other HCW, female, vaccinated)

HCWs interact with patients and are tasked with addressing patient queries. HCWs reported having to allay patient concerns related to the safely of COVID-19 vaccines. HCWs well versed with the potential risks of the vaccine were able to effectively communicate the extent of the risk, drawing on their clinical training.

One of the females [said] “I’m going to get a blood clot, I’m taking hormone replacement therapy”. So, I would respond"well I am on hormone replacement therapy and here are the stats, you’ll have a greater chance of having a thrombosis [blood clot] from the hormone replacement itself as opposed to a vaccine". (P11, Other HCW, female, vaccinated)

Vaccinated HCWs were also able to share their personal experiences as a strategy to alleviate patient fears.

I don’t want to sugar coat anything or sell people lies. So I tell them my experience of the vaccine, that okay, when I had the vaccine I only had a headache, and it lasted for three daysThat’s what happened to me, so especially with family members, I got them to vaccinate. (P21, Other HCW, female, vaccinated)

Some HCWs didn’t feel the vaccine was necessary for everyone, and rather focused their energy on convincing patients and family members considered to be at high risk, to get vaccinated.

I do not need to be vaccinated, but I do agree that those who are at risk should be vaccinated, the people with comorbidities … like my husband is hypertensive, so I encouraged him to be vaccinated. And the elderly like my mother, she’s also been vaccinated because she had COVID in the beginning of 2021. I think those are the people who I would see as people who are high risk and who need to be vaccinated. (P17, Nurse, female, unvaccinated)

Challenges facing HCWs in administering and promoting COVID-19 vaccination

Some HCWs felt conflicted about actively promoting vaccination because it was incongruent with their personal beliefs.

I’m conflicted, but duty bound. So my personal opinion about the subject matter I normally shove aside. I do not share with patients, I don’t want to be labelled that I am misleading the public. I don’t do that. Whatever I’ve shared with you, I don’t share with the public. Because being in the position that I am in, I may find it problematic, and I may be called into question and I may be regarded as misleading the public. (P3, Nurse, male, unvaccinated)

Participants raised concerns about not having sufficient information or the ability to respond adequately to the questions posed by patients. Several HCWs felt that their own knowledge deficit resulted in them struggling to navigate through conversations with patients about the COVID-19 vaccines.

I mean, there’s all these new vaccines again, and talking about covering the different variants. I don’t even know if I need another booster shotif I don’t know it for myself, there’s no way I can teach it to a patient. Yeah, especially with the newer updates. I definitely do not know enough to be able to adequately educate patients regarding this. (P19, Doctor, male, vaccinated)

Several participants expressed frustration regarding their lack of accessible information to address questions raised by patients.

The old age home pressurised everybody [to vaccinate], and a lot of people didn’t ask beforehand, they came back later, and said “What’s happening to me?”So there was a lot of frustration around this whole thing, where they said: “Why should I vaccinate if I sit in my office and am not in contact with many people, just because it’s policy?” So yes, it was difficult to give proper answers, because it didn’t make sense to me either… I can’t lie. This is who I am. I can’t tell people a story that I can’t scientifically qualify. (P26, Doctor, female, unvaccinated)

Several HCWs also described how they often had similar questions and concerns as the public about the COVID-19 vaccines.

…so obviously because I’m working for the company, I also need to motivate people to do vaccination. So, most of our patients, when I do the call, they ask if the vaccine is appropriate. I also have those questions. (P30, Other HCW, female, unvaccinated)

Rationale for HCWs discouraging vaccination and promoting alternative medicine

Some HCWs discouraged patients from getting vaccinated based on perceived clinical and anecdotal evidence suggesting harmful effects of the vaccine.

So I haven’t taken it and I’m telling every patient coming in here, they should not take it, and then I show them all my cases, how many strokes there were, deaths there were, all the side-effects, and I’m sure they are convinced. I tell them or show them. I’ve got some articles and even some little YouTube clips just stating the obvious and I show them all my statistics.

Interviewer: So you don’t recommend to patients or anyone to get vaccinated?

Never. In the beginning I was hesitant, hesitating because I wasn’t sure whether the vaccine was more beneficial than harmful, but as time progressed, I can clearly see with my own eyes and I read from all over the world, the vaccine is not helpful and it’s not beneficial. There’s no benefit, it’s more harmful than beneficial. (P8, Doctor, male, unvaccinated)

A minority of HCWs advocated for alternative prevention and treatments. Some HCWs leaned towards treatment rather than prevention and believed that medication already existed that would be beneficial for infected patients, or that could be used as prophylaxis.

I started people immediately on vitamin C and zinc and those basics. But I’ve seen actually many, many side-effects just with vitamin C because it’s so toxic on your gastric liningSo that was a bit of a worry. Zinc works with any viral disease, zinc works. It definitely makes a difference. The people who were more at risk I put on ivermectin, and it made an incredible difference. And since ivermectin got the Nobel Prize, I think in 2014 or 2015 for being such a safe medicine after how many million dosages. It’s a wonderful anti-parasitic as well by the way. I’m actually very sad that they stopped it. (P26, Doctor, female, unvaccinated)

Some HCWs felt strongly about the use of ivermectin, a widely used antiparasitic medicine with known antiviral and anti-inflammatory properties to treat COVID-19. They expressed a clear stance that the government should not have prohibited HCWs from prescribing it.

The South African government does not want us to use ivermectin, crazy. That drug has a Nobel Prize attached to it, it’s been used safelythey don’t want us to use it, they want us to use very expensive drugs. (P7, Doctor, male, unvaccinated)


This study undertook a national cross-sectional survey of South African HCW willingness to recommend COVID-19 vaccination to patients in relation to their own vaccination behavior, use of alternative medicine, and availability of information. Using qualitative data, an examination was done of HCW views on vaccines, types of engagements with patients, and the perceived value of alternative remedies.

The results showed that a high proportion (91%) of the HCWs in this study had been vaccinated. This correlated with the majority (82%) who indicated that they were willing to recommend vaccination to patients, family, and friends. The data suggest that there was a lower proportion of HCWs willing to recommend vaccines to pregnant women (61%) and children (73%). These findings affirm results from an Italian study on whether HCWs would recommend vaccination to their patients.25 Papini et al.25 found that only a small percentage of participants (1.7%) would not recommend the COVID-19 vaccine to their relatives, and even fewer participants (0.9%) would not recommend it to their patients. As in the Italian study, the present study found consistency between HCWs’ personal vaccine behaviour and their willingness to promote vaccination; 9% of the sample were unvaccinated, and only 19% were not prepared to recommend the vaccine. A higher proportion of unvaccinated HCWs, compared with their vaccinated colleagues, were unwilling to promote vaccines. However, within the unvaccinated group, some still saw the benefit of, or felt duty-bound to recommend vaccines, with the qualitative data revealing that some HCWs found vaccines particularly beneficial for patients in high-risk groups. The results of the present study affirm data from one of the few studies done on HCW engagement with patients around COVID-19 vaccines,26 which concluded that vaccine-hesitant HCWs were reluctant to promote vaccines, citing fear of inducing patient anxieties or complaints.

With only 51% of the South African adult population vaccinated by the end of January 202321 and with research suggesting that HCWs remain a trusted source of information in their communities,27–29 it is evident that HCWs have not been adequately educated and utilised in the promotion of vaccination. The literature highlights HCWs’ pervasive sub-optimal knowledge and communication skills around COVID-19 vaccination, which has negatively impacted interactions with patients30 and possibly affected vaccine uptake. While HCWs participating in this study appeared perspicacious, an unmet appetite for additional up-to-date information remains, especially given that this is a relatively novel virus resulting in an evolving sequence of variants and understandings of its effects and effective available treatment and prevention options. The quantitative results of the present study revealed that the majority of participants (59%) felt that they did not have sufficient knowledge of the available COVID-19 vaccines, and a similar proportion (60%) required additional guidance on how to educate patients about COVID-19 and the available vaccines. Further analysis indicates that these factors negatively affected HCW willingness to promote vaccination to patients. Even for those HCWs willing to promote vaccination, the reportedly inadequate information at their disposal made their task more challenging. This is not unique, with other studies reporting that HCWs found it difficult to discuss vaccines knowledgeably with peers and patients.26 Qualitative analysis in the present study revealed the benefits of having HCWs well versed in the risk and benefits of vaccines, resulting in better communication and ability to adequately address patients’ questions and fears.

This study further revealed that HCWs who personally used alternative medication to treat or prevent COVID-19, were less inclined to promote vaccination. Further, those recommending alternative approaches were less likely to recommend vaccines, suggesting that HCWs are not necessarily promoting alternative medication to supplement vaccines, but in some cases they are promoting it as a substitute. This study data supports this assertion, with some HCWs arguing for the benefits of alternative approaches such as traditional African medication, vitamins, and therapeutics such as ivermectin. There are limited studies on HCW prescription and promotion of alternative medicine. In China, scientists and doctors initially recommended using Traditional Chinese Medicine (TCM) as a cure for COVID-19.31 During the SARS epidemic, TCM had reportedly been effective in the treatment of infected people, and the Chinese Government ordered the use of TCM to treat COVID-19 patients. It was reported that about 85% of COVID-19 patients in China received combined treatment with TCM and regular medication. This stance is not parochial, as the World Health Organization (WHO) welcomes innovations such as traditional medicine, repurposed drugs, and development of new therapies. Africa and some parts of Asia have a long history of using traditional medicine, and the WHO recognises the many benefits of traditional medicines.31 In addition, the emergence of conflicting published results on some proposed therapeutic alternatives, including ivermectin, has added to confusion surrounding viable therapeutic alternatives.32,33 This led to support for the drug across social media and by some organisations.34 This was picked up by HCWs and the public, including in South Africa, with some anti-vaxxers extolling the benefits of ivermectin.35 A study in India explored knowledge and practices around ivermectin as a potential pre-exposure prophylaxis (PrEP.). They found that the majority (70.59%) of the sample of HCWs believed that ivermectin was protective against COVID-19, while more than half (57.37%) of the sample used or recommended the drug.36 While advocacy for ivermectin and other alternative medicine among this sample was small, it suggests a lack of clear messaging, affirming the need to improve institutional communication addressed to HCWs to enhance their role as vaccination facilitators.37

For HCWs to promote vaccines effectively to the public, they need both current scientific knowledge and communication skills. This was and continues to be challenging within an emergency context, and continues to evolve as different variants of the virus emerge and more efficacious vaccines and therapeutics become available. There remain numerous sources of information, all made more easily accessible through increased use of the internet and social media – many of these sources provide informative and valuable information, but some propagate misinformation, sometimes persuasively. HCWs require trusted sources of information that deliver updated evidence-based messages that are easily understood by all cadres of HCWs. The value of the present study extends beyond the role of HCWs in promoting COVID-19 vaccines but applies to national immunisation programmes more broadly. Patients, are likely to question both the benefit and safety of available vaccines, with HCWs expected to communicate reliably from a clear evidence base.

The findings of this study contribute to the few studies to date that have explored HCW interactions with patients around COVID-19 vaccines. Specifically, there remains a dearth of data on HCW interactions with patients on the issue of COVID-19 vaccines in the South African and broader African context. A strength of the study is that it employed mixed methods, using both qualitative and quantitative approaches to fully capture the form and content of HCW engagement with patients in South Africa.

Use of an unrestricted self-administered survey was a limitation as the survey was dependent on HCW access to selected online databases. This limitation may have introduced selection bias and limited generalisability. Further, geographical distribution of the study participants was not factored into the survey and was therefore not known, and individual interpretation of the term ‘patients’ may have influenced how HCWs rated their willingness to promote vaccines.


This study indicates that personal vaccine behaviour of HCWs largely mirrored their willingness to promote vaccination to patients. This is positive given the high proportion of HCWs who were vaccinated and who were subsequently willing to assume the role of vaccine advocates. A large number of HCWs stated that they did not have sufficient information on the available vaccines, contributing to the majority who felt that they needed reliable guidance on how to educate patients. The data indicate that these factors contribute to HCW willingness to promote vaccines to patients. Although a minority, the study revealed that some unvaccinated HCWs were taking and recommending alternative therapies, possibly a consequence of a lack of clear, comprehensible, evidence-based and reliable sources of vaccine information. Therefore, if HCWs are to become the fulcrum of national vaccination programmes, they will need to be provided with clear, contextual, up-to-date evidence-based information, to enhance both workflow and patient communication.


Funding: The DRILL project was supported by the Fogarty International Centre (FIC), National Institutes of Health (NIH) Common Fund, Office of Strategic Coordination, Office of the Director (OD/OSC/CF/NIH), Office of AIDS Research, Office of the Director (OAR/NIH), and National Institute of Mental Health/National Institutes of Health (NIMH/NIH) under award number D43TW010131 (under the scientific areas of HIV/AIDS, mental health, health professions education, health research ethics, and health systems research). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Conflicts of interests

Douglas Wassenaar is the Chair of the University of KwaZulu-Natal Biomedical Research Ethics Committee (BREC) that approved this study. The conflict of interest was declared to BREC and this application was managed independently by a BREC Deputy-Chair. The other authors declare no conflict of interest.

Abbreviation Description
BREC Biomedical Research Ethics Committee
CI confidence interval
COVID-19 coronavirus disease 2019
DOH Department of Health
FPD Foundation for Professional Development
HCW healthcare worker
IDI in-depth interview
OR odds ratio
PrEP pre-exposure prophylaxis
SARS severe acute respiratory syndrome
TCM Traditional Chinese Medicine
WHO World Health Organization