The high-education paradox in hepatitis B vaccination: structural barriers, role conflict, and implications for...

The aims of this study were to investigate the paradoxical association between higher educational attainment and lower completion of hepatitis B vaccination among healthcare workers (HCWs) in a high-workload tertiary hospital in China and to identify structural and cognitive determinants of vaccination behaviour.

We conducted a mixed-method study in 2025 that integrated a cross-sectional survey of 628 HCWs using stratified random sampling with 28 in-depth interviews. Multi-variable logistic regression was used to identify factors associated with completion of the full-course vaccination, with additional sensitivity analyses performed to assess robustness. A thematic analysis of interview data was conducted to explore mechanisms underlying the quantitative findings.

Full-course vaccination coverage was 44.1%. Older age (adjusted odds ratio [aOR]: 1.09), prior needlestick injury (aOR: 1.45), and thorough knowledge of vaccine safety and efficacy (aOR: 4.32) were associated with higher completion. In contrast, holding a master's degree (aOR: 0.51) and perceived time constraints (aOR: 0.53) were associated with lower completion. Dose distribution analysis indicated that master's degree holders had not only the highest proportion of unvaccinated individuals (53.8%) but also the highest completion rate among those who initiated vaccination (83.8%). Qualitative findings highlighted structural time scarcity, role conflict, and misalignment between vaccination services and clinical workflows as key barriers.

The 'high education, low vaccination' paradox primarily reflects systemic barriers within high-demand health systems rather than individual knowledge deficits. Educational attainment, rather than occupation itself, appears to mark differential exposure to structural constraints, with advanced-degree holders experiencing greater role conflict and time pressure regardless of professional title. Interventions should therefore move beyond individual education and focus on integrating vaccination services into routine clinical workflows. Suboptimal vaccination coverage also represents a vulnerability in hospital infection prevention systems. Unvaccinated HCWs who acquire infection after occupational exposure may serve as potential sources of nosocomial hepatitis B virus transmission, particularly during exposure-prone procedures. Addressing structural barriers to vaccination is therefore essential not only for occupational health protection but also for strengthening hospital infection control and patient safety.