Background: Hepatitis B virus (HBV) infection is a significant public health concern in sub-Saharan Africa, with healthcare workers (HCWs) at elevated occupational risk due to frequent exposure to blood and bodily fluids. As a preventive measure, the implementation of mandatory vaccination policies for HCWs has gained attention globally. However, the ethical implications of such policies, particularly in low-resource settings, remain underexplored. This scoping review aims to examine the ethical considerations surrounding the implementation of mandatory Hepatitis B vaccination policies among healthcare workers in sub-Saharan Africa.

Methodology: A scoping review approach was adopted to systematically explore the literature related to mandatory vaccination policies for HCWs in sub-Saharan Africa, focusing on ethical issues. A comprehensive search strategy was employed, utilizing multiple academic databases, including PubMed, Scopus, and Google Scholar. Studies were selected based on predetermined inclusion and exclusion criteria. Relevant articles addressing ethical concerns, policy frameworks, and vaccination uptake were analyzed to identify key themes and insights.

Ethical Considerations: The review highlights several ethical principles involved in mandatory vaccination policies, including beneficence, nonmaleficence, autonomy, and justice. Key ethical challenges identified include balancing public health objectives with individual autonomy, ensuring equitable access to vaccines for all healthcare workers (especially those in rural or marginalized areas), and addressing the moral responsibility of healthcare workers to protect their patients and colleagues. Additionally, ethical governance structures and transparent policy enforcement are discussed to ensure fairness and accountability.

Conclusion: The review concludes that while mandatory vaccination policies are essential for protecting public health and occupational safety, they must be designed with careful attention to ethical principles. Policymakers must prioritize justice, equity, and transparency, while also considering the diverse socio-cultural and economic contexts in which these policies are implemented. Further research is needed to explore the long-term effects and sustainability of such policies in sub-Saharan Africa.

Keywords: Hepatitis B; Healthcare Workers; Mandatory Vaccination; Ethical Considerations; Sub-Saharan Africa, Public Health Policy

Background on Hepatitis B and Healthcare Workers

Hepatitis B virus (HBV) infection remains a major global public health challenge, particularly in low- and middle-income countries [1-6]. HBV is a highly infectious viral pathogen that primarily affects the liver, potentially leading to chronic hepatitis, cirrhosis, and hepatocellular carcinoma [5-10]. According to the World Health Organization (WHO), an estimated 296 million people worldwide were living with chronic HBV infection as of 2019, with the majority residing in sub-Saharan Africa [8]. The region bears a disproportionate burden of HBV due to high prevalence rates, limited access to healthcare, and inadequate implementation of preventive measures [8].

Healthcare workers (HCWs) are at an elevated risk of acquiring HBV infection due to their occupational exposure to blood and other bodily fluids [11-15]. The Centers for Disease Control and Prevention (CDC) estimates that HCWs are 2–4 times more likely to contract HBV than the general population, particularly in high-prevalence regions [14]. Procedures such as needle-stick injuries, surgical operations, and handling of contaminated medical equipment are significant risk factors contributing to occupational exposure [11]. In sub-Saharan Africa, where healthcare systems are often resource-constrained, the lack of proper personal protective equipment (PPE), inadequate training, and limited access to post-exposure prophylaxis (PEP) exacerbate the vulnerability of HCWs to HBV [12].

The consequences of HBV infection among HCWs extend beyond personal health risks. Infected HCWs may unintentionally transmit the virus to their patients, undermining trust in healthcare systems [16-18]. Moreover, chronic HBV infections among HCWs can lead to workforce attrition, further straining already overstretched healthcare systems in sub-Saharan Africa. As a result, the prevention of HBV among HCWs is not only a critical occupational health priority but also a key strategy for ensuring safe and effective healthcare delivery in the region [16].

Mandatory Vaccination Policies

Vaccination against HBV is one of the most effective measures for preventing infection [15-18]. The WHO recommends that all HCWs receive the full three-dose series of the HBV vaccine, as it provides over 95% protection against the virus [16]. Despite this, vaccine coverage among HCWs in sub-Saharan Africa remains suboptimal, with significant gaps in uptake attributed to various barriers, including vaccine cost, inadequate supply, and limited awareness of the vaccine’s benefits [19-32]. Globally, mandatory vaccination policies have emerged as a strategy to enhance vaccine coverage among HCWs [33-35]. These policies require healthcare personnel to be vaccinated as a condition for employment or continued practice, aiming to reduce the risk of occupational infections and ensure patient safety. In high-income countries, such policies have successfully increased vaccine uptake and reduced the incidence of HBV among HCWs [36-39]. For example, in some developed countries such mandatory HBV vaccination for HCWs has been a cornerstone of occupational health programs [40-43].

In sub-Saharan Africa, the implementation of mandatory vaccination policies is far less common [40]. While some countries have introduced recommendations or guidelines for HBV vaccination among HCWs, enforcement mechanisms and resources to support vaccine availability are often lacking. The disparities in vaccination policy implementation between high- and low-income regions highlight the need to critically evaluate the feasibility, acceptability, and ethical implications of mandatory vaccination in resource-limited settings [44].

Rationale for the Scoping Review

The implementation of mandatory HBV vaccination policies for HCWs raises important ethical questions, particularly in sub-Saharan Africa, where healthcare systems face unique challenges [45-53]. Mandatory vaccination involves balancing the rights of individual autonomy with the collective responsibility to protect public health. For HCWs, this balance becomes even more complex, as their professional duty to prevent harm to patients must also be weighed against their personal beliefs, cultural norms, and access to healthcare resources [45-54].

Ethical concerns surrounding mandatory vaccination policies include issues of equity, justice, and consent [55]. In resource-limited settings, where vaccine access may be inconsistent, mandating vaccination could inadvertently exclude or penalize certain groups of HCWs, such as those working in rural or informal healthcare settings. Furthermore, the potential for coercion in enforcing mandatory policies must be addressed to ensure that HCWs retain their right to informed decision-making [56].

Despite the critical importance of these ethical considerations, there is limited literature that specifically explores the ethical dimensions of mandatory HBV vaccination policies in sub-Saharan Africa. This gap in knowledge underscores the need for a comprehensive scoping review to identify and analyze existing evidence, providing a foundation for ethically sound policy recommendations that are tailored to the unique context of the region.

Furthermore, the literature on mandatory Hepatitis B vaccination for healthcare workers (HCWs) in sub-Saharan Africa reveals critical gaps and contradictions. Most studies are cross-sectional, rely on self-reports, limiting reliability and insights into long-term outcomes. Evidence is skewed toward urban contexts, neglecting rural regions. Definitions of “mandatory” vaccination vary, creating inconsistent conclusions. Ethical arguments often overlook systemic barriers like shortages and weak enforcement. Equity concerns persist, as marginalized HCWs, such as trainees and volunteers are underrepresented, leaving policies vulnerable to reinforcing inequities and lacking context-sensitive, ethically sound guidance.

Objectives and Research Questions

This scoping review aims to examine the ethical considerations surrounding the implementation of mandatory HBV vaccination policies for HCWs in sub-Saharan Africa. By synthesizing evidence from existing literature, the review seeks to provide insights into the ethical challenges, opportunities, and implications of such policies.

The review is guided by the following key research questions:

1. What are the ethical principles and frameworks relevant to mandatory HBV vaccination policies for HCWs?
2. What are the primary ethical concerns associated with implementing mandatory vaccination policies in sub-Saharan Africa?
3. How do contextual factors, such as resource availability, cultural norms, and healthcare infrastructure, influence the ethical feasibility of these policies?
4. What strategies have been proposed or implemented to address ethical challenges in mandatory vaccination policies, and how effective are they?
5. What policy recommendations can be made to ensure ethical and equitable implementation of mandatory HBV vaccination for HCWs in sub-Saharan Africa?

The methodology for this scoping review is informed by the framework proposed by Arksey and O'Malley, with enhancements suggested by Levac and colleagues [57,58]. This approach is particularly suitable for exploring broad and multifaceted topics, such as the ethical dimensions of implementing mandatory Hepatitis B (HBV) vaccination policies among healthcare workers (HCWs) in sub-Saharan Africa. The methodology ensures a systematic and transparent process for identifying, selecting, and analyzing literature to provide a comprehensive understanding of the research question.

Scoping Review Framework

The scoping review methodology provides a structured way to map existing literature and examine the extent, range, and nature of evidence available on a particular topic. This approach was chosen because it allows for the synthesis of evidence across diverse sources, including peer-reviewed articles, policy documents, and gray literature, which is particularly important for a topic as nuanced as the ethical implications of vaccination policies. The review process began with defining the research questions, focusing on ethical principles, challenges, and contextual factors influencing the adoption of mandatory HBV vaccination policies in sub-Saharan Africa. The study aims to understand not only the ethical dilemmas but also the practical implications of such policies on healthcare workers in the region.

Once the research questions were established, a systematic search strategy was designed to capture the most relevant and high-quality studies. Studies were included based on their relevance to healthcare workers, Hepatitis B vaccination, mandatory policies, and ethics, particularly in the context of sub-Saharan Africa. The selected studies were analyzed to identify recurring themes, ethical arguments, and gaps in the literature. To ensure methodological rigor, the review process involved iterative consultations among the researchers to refine the inclusion and exclusion criteria and resolve discrepancies in study selection. This approach aligns with best practices for scoping reviews, ensuring that the findings are robust and reflective of the current state of knowledge.

Sources and Search Strategy

The success of a scoping review depends heavily on the comprehensiveness of its search strategy. For this review, multiple sources were explored to capture a wide range of perspectives on the topic. Both peer-reviewed literature and gray literature were included to minimize publication bias and provide a holistic understanding of the subject. The search was conducted across several databases, including PubMed/MEDLINE, Scopus, Web of Science, African Journals Online (AJOL), and the WHO Global Health Library. These databases were selected for their relevance to public health, healthcare, and ethical issues in global and regional contexts. A combination of keywords and Boolean operators was used to ensure a thorough search. Keywords included terms such as "Hepatitis B," "healthcare workers," "mandatory vaccination policies," "ethics," and "sub-Saharan Africa." These terms were combined with Boolean operators (AND, OR) to refine the search and retrieve the most pertinent studies.

The inclusion criteria were clearly defined to ensure the relevance of the selected studies. Only studies published in English were included due to resource limitations. The review focused on literature that addressed HBV vaccination, healthcare workers, and ethical considerations, with a specific emphasis on sub-Saharan Africa. Studies not addressing these aspects or focusing on unrelated diseases or regions were excluded. The search process involved multiple steps, starting with an initial screening of titles and abstracts to identify potentially relevant studies. This was followed by a full-text review of shortlisted articles to determine their suitability for inclusion in the review. Any disagreements during the screening process were resolved through discussion among the researchers, ensuring consistency and objectivity. To enhance the reliability of the findings, gray literature such as policy briefs, reports from health organizations, and conference proceedings were also included. This was particularly important for capturing insights into the practical and policy-related aspects of mandatory HBV vaccination in sub-Saharan Africa.

Ethical Considerations in the Review Process

Ethical considerations were integral to the methodology of this scoping review. Although the study is based on existing literature and does not involve human participants, adherence to ethical principles ensured rigor, transparency, and relevance throughout the review process. One key ethical consideration was transparency in the review process. All steps, from the development of the search strategy to the analysis of findings, were meticulously documented. This included maintaining detailed records of the databases searched, search terms used, and criteria for study selection. Efforts were made to minimize bias by including a diverse range of sources and perspectives. The inclusion of gray literature and regional studies helped ensure that the findings were not skewed towards high-income countries or mainstream journals, which may not fully capture the realities of healthcare workers in sub-Saharan Africa. Dual screening and data extraction by two independent reviewers further enhanced the reliability and validity of the findings. Proper acknowledgment of intellectual property was another critical ethical consideration. All included studies were cited appropriately to recognize the contributions of the original authors and ensure compliance with academic standards.

Finally, relevance to local contexts was prioritized to ensure that the findings are meaningful and applicable to the healthcare systems and ethical frameworks of sub-Saharan Africa. By focusing on studies that address the unique challenges and cultural factors of the region, the review aimed to provide insights that are not only theoretically robust but also practically actionable. In conclusion, the methodology adopted for this scoping review combines a rigorous framework with a comprehensive search strategy and strict adherence to ethical principles. This approach ensures a systematic and transparent synthesis of the literature, providing valuable insights into the ethical dimensions of mandatory HBV vaccination policies for healthcare workers in sub-Saharan Africa.

Ethical Justifications for Mandatory Vaccination Policies

The implementation of mandatory vaccination policies, particularly for healthcare workers, raises complex ethical questions that must be carefully examined. These policies are often justified on the grounds of protecting public and occupational health, fulfilling professional responsibilities, and balancing individual autonomy with collective societal obligations [59]. Exploring these justifications in depth reveals the ethical underpinnings that make such policies not only necessary but also defensible in certain contexts, particularly in settings like sub-Saharan Africa, where the burden of infectious diseases like Hepatitis B remains high (Table 1).

At the core of mandatory vaccination policies lies the ethical principle of beneficence, which emphasizes the obligation to act in ways that promote the well-being of others [59]. In the context of healthcare, beneficence extends to protecting patients, colleagues, and the broader community from preventable infectious diseases [59-61]. For healthcare workers who are at a higher risk of exposure to the Hepatitis B virus (HBV), vaccination serves as a critical tool to reduce the risk of transmission within healthcare settings [40]. Equally important is the principle of nonmaleficence, which obligates individuals and institutions to prevent harm [60]. Healthcare workers, by the nature of their work, can inadvertently become vectors for the transmission of HBV, placing their patients, especially those who are immunocompromised or vulnerable, at risk. Ensuring that healthcare workers are vaccinated minimizes this occupational hazard, thereby upholding the commitment to “do no harm.” Mandatory vaccination policies are also supported by the concept of herd immunity, which underscores the collective benefit of widespread immunization [61-64]. By ensuring that healthcare workers are vaccinated, the likelihood of HBV outbreaks within healthcare facilities is significantly reduced, protecting both workers and patients. This protective effect is particularly critical in sub-Saharan Africa, where healthcare infrastructure is often overstretched and the ability to manage outbreaks is limited. In such settings, the ethical imperative to prioritize public and occupational health becomes even more pressing [64].

Duty of Care and Professional Responsibility

Healthcare workers have a unique professional obligation to safeguard the health and well-being of their patients [59]. This duty of care is rooted in the ethical principles of fidelity and responsibility, which require healthcare workers to prioritize the interests of their patients and act in ways that promote trust and confidence in the healthcare system [60]. Vaccination against HBV is an extension of this professional duty, as it reduces the risk of transmission and ensures that healthcare workers can provide care without exposing patients to preventable harm [40]. In addition to their obligations to individual patients, healthcare workers have a broader responsibility to society. The healthcare profession is fundamentally built on the principle of altruism, where individuals commit to serving the greater good, often at personal cost [40]. This commitment includes taking reasonable measures to protect themselves and others from infectious diseases. Mandatory vaccination policies can be seen as a formalization of this ethical obligation, ensuring that healthcare workers uphold their professional responsibilities in a consistent and equitable manner [40]. However, it is also essential to recognize that the duty of care is not one-sided. Employers and policymakers have an ethical responsibility to support healthcare workers by providing access to vaccines, clear information about their safety and efficacy, and addressing any barriers that might prevent compliance. Without such support, mandatory vaccination policies risk being perceived as coercive or unfair, undermining their ethical foundation [62-64].

5.2. Balancing Individual Autonomy and Collective Responsibility

One of the most contentious aspects of mandatory vaccination policies is the tension between individual autonomy and collective responsibility [65]. Autonomy is a cornerstone of modern bioethics, emphasizing the right of individuals to make decisions about their own bodies and health [66]. For healthcare workers, this includes the right to accept or refuse vaccination based on personal beliefs or preferences. However, autonomy is not an absolute right and must be weighed against the potential harm that individual choices can cause to others. In the context of infectious diseases like HBV, the refusal to vaccinate can have far-reaching consequences, not only for the individual but also for patients, colleagues, and the broader community. This creates a moral and ethical imperative to prioritize collective responsibility over individual choice in certain circumstances [67].

The principle of justice also plays a crucial role in this balance. Healthcare workers who choose not to vaccinate may inadvertently place an unequal burden on their vaccinated colleagues, who are left to bear the risks of exposure and the responsibility of maintaining a safe healthcare environment [68-69]. Mandatory vaccination policies help to distribute these responsibilities more equitably, ensuring that all healthcare workers contribute to the collective effort to protect public health [70]. Ethical frameworks such as utilitarianism, which emphasize maximizing overall well-being, further support the implementation of mandatory vaccination policies. From this perspective, the potential benefits of widespread vaccination, such as reduced HBV transmission, improved patient safety, and enhanced public trust in the healthcare system, outweigh the costs of limiting individual autonomy. At the same time, it is essential to ensure that such policies are implemented with sensitivity and respect for individual rights, minimizing the risk of alienation or resentment among healthcare workers [71-72].

Hence, the ethical justifications for mandatory vaccination policies are deeply rooted in the principles of beneficence, nonmaleficence, and justice, as well as the professional obligations of healthcare workers to prioritize the well-being of their patients and society [69]. While these policies inevitably involve trade-offs between individual autonomy and collective responsibility, their ultimate goal is to protect public and occupational health in a manner that is equitable, effective, and ethically sound [72]. Ensuring that these justifications are clearly communicated and supported by robust policy frameworks is essential to their successful implementation, particularly in regions like sub-Saharan Africa, where the stakes are highest.

The implementation of mandatory Hepatitis B vaccination policies among healthcare workers (HCWs) in sub-Saharan Africa faces a multitude of challenges that span resource constraints, workplace policies, and workforce dynamics [73-94]. These challenges are deeply rooted in the socioeconomic realities of the region, the structural limitations of healthcare systems, and the ethical dilemmas that arise when attempting to balance individual rights with public health imperatives.

Resource Constraints and Accessibility

One of the most significant challenges in implementing mandatory Hepatitis B vaccination policies is the issue of resource constraints. Sub-Saharan Africa bears a disproportionate burden of Hepatitis B virus (HBV) infections, yet the availability and affordability of vaccines remain a critical barrier [95-97]. In many countries within the region, healthcare systems are underfunded, with limited budgets allocated for immunization programs. This financial constraint often results in inadequate vaccine supplies, leaving many HCWs without access to the protection they urgently need. The affordability of the Hepatitis B vaccine is another pressing concern. While the vaccine is highly effective in preventing HBV infections, its cost can be prohibitive for many healthcare facilities and workers, particularly in low-income settings. In some cases, healthcare workers are expected to bear the cost of vaccination themselves, which can be a significant burden given the relatively low salaries in the sector [98]. This situation raises questions about equity and fairness, particularly when HCWs are exposed to occupational risks of HBV infection through their professional duties. In addition to financial barriers, logistical challenges such as cold chain requirements for vaccine storage further hinder accessibility. Many healthcare facilities in sub-Saharan Africa lack the infrastructure needed to store and transport vaccines safely, leading to stockouts and wastage [99-104]. These logistical hurdles disproportionately affect rural and remote areas, where healthcare workers are already underserved and face higher risks of infection due to limited protective equipment and resources [99].

Workplace Policies and Enforcement

The enforcement of mandatory vaccination policies in resource-limited settings poses significant ethical and practical challenges. While such policies are intended to protect HCWs and the broader population from HBV, their implementation can lead to unintended consequences. One major concern is the potential for coercion, where healthcare workers may feel pressured to comply with vaccination requirements without fully understanding the risks and benefits or without having access to adequate information [59-70]. The lack of clear and consistent workplace policies further complicates the situation. In many healthcare settings in sub-Saharan Africa, there are no standardized guidelines for implementing mandatory vaccination policies. This absence of uniformity can lead to disparities in enforcement, where some healthcare workers are vaccinated while others are not, based on the resources or priorities of their respective institutions. Such inconsistencies can undermine the perceived legitimacy of vaccination policies and lead to mistrust among HCWs. Moreover, enforcement in resource-limited settings often raises ethical questions about the balance between individual autonomy and collective responsibility. While mandatory vaccination policies aim to reduce the risk of HBV transmission within healthcare settings, they can also infringe on the personal freedoms of HCWs, particularly when alternative measures, such as regular screening and the provision of protective equipment, are not adequately provided. These ethical dilemmas are further compounded by the lack of legal frameworks to support the enforcement of such policies, leaving healthcare institutions to navigate complex and sensitive issues without clear guidance.

Healthcare Workforce Dynamics

The introduction of mandatory vaccination policies can have profound implications for healthcare workforce dynamics, particularly in regions like sub-Saharan Africa, where healthcare systems are already strained by shortages of trained personnel. One potential challenge is the impact of such policies on workforce morale. If mandatory vaccination is perceived as coercive or unfair, it can lead to resentment and resistance among healthcare workers, undermining their trust in healthcare institutions and policymakers [105]. Recruitment and retention of healthcare workers may also be affected by mandatory vaccination policies. In a region where the healthcare workforce is already under significant pressure due to high workloads, low salaries, and poor working conditions, the introduction of additional requirements such as mandatory vaccination could deter prospective HCWs from entering the profession [106-107]. Existing workers may also consider leaving their positions, particularly if they perceive vaccination policies as an added burden or an infringement on their personal rights. These challenges are further exacerbated by the stigma and fear associated with HBV infections in some communities. In settings where misconceptions about the vaccine or the disease itself persist, healthcare workers may face additional social pressures that influence their willingness to comply with vaccination policies. Addressing these fears and misconceptions requires targeted educational campaigns and ongoing engagement with HCWs to build trust and support for vaccination efforts [108-110].

Equity and Justice in Policy Design

When implementing mandatory vaccination policies, particularly in resource-limited settings like sub-Saharan Africa, the principles of equity and justice are of paramount importance [59-61]. These ethical frameworks provide the foundation for ensuring that healthcare workers, regardless of their location, status, or role, have fair and equal access to vaccines. The challenges of equitable distribution and access are particularly pronounced in this context, where disparities in healthcare access, infrastructure, and resources can lead to unequal outcomes. Therefore, addressing these disparities and ensuring that marginalized groups are not excluded or left behind are key ethical imperatives in the policy design process.

Addressing Disparities

One of the primary challenges in implementing a mandatory vaccination policy for healthcare workers is ensuring that all individuals have fair access to the vaccine, especially those in underserved or rural areas. In many parts of sub-Saharan Africa, healthcare infrastructure is severely limited, with significant gaps in both the availability and accessibility of essential healthcare services. These areas often face challenges in vaccine distribution, with logistical issues such as transportation difficulties, a lack of refrigeration facilities, and shortages of trained healthcare personnel further exacerbating the problem. The ethical principle of equity demands that all healthcare workers, regardless of their geographical location, have access to the same protections against infectious diseases like Hepatitis B [111]. This requires careful consideration of the specific needs and challenges faced by healthcare workers in rural and remote areas. It is not enough to mandate vaccination policies in urban centers or well-resourced hospitals while overlooking the needs of healthcare workers in rural regions. The equitable distribution of vaccines involves providing adequate resources to ensure that vaccines are available, accessible, and administered to all healthcare workers who need them, regardless of where they are based [112]. Furthermore, equity in vaccine access also involves addressing social and economic barriers that may prevent healthcare workers from seeking or receiving the vaccine [113]. For instance, healthcare workers in rural areas may face financial constraints that limit their ability to travel to vaccination centers, especially if transportation costs are high or infrastructure is lacking [114]. Policies must therefore be designed in such a way that they not only provide vaccines but also ensure that the systems for accessing them are affordable and accessible [115]. This may involve outreach programs, mobile vaccination clinics, or subsidized transportation to ensure that rural healthcare workers are not left behind. In addition to geographic disparities, policies should account for the differing levels of healthcare access within countries, particularly between public and private healthcare settings [116-117]. In many cases, healthcare workers in public hospitals may be at greater risk of exposure to infectious diseases due to overcrowding and limited resources, and they may also face more significant barriers to vaccination. Addressing these disparities ensures that all healthcare workers are equally protected, regardless of the type of healthcare facility in which they work.

Mandatory vaccination policies must address not only geographic disparities but also the needs of marginalized healthcare workers, including contract staff, volunteers, and informal providers [118]. These groups often lack job security, benefits, or access to workplace health programs, leaving them vulnerable to exclusion from vaccination initiatives. Such exclusion creates a two-tiered system that compromises both worker and patient safety, raising serious ethical concerns [119]. Informal healthcare workers, such as community health workers or traditional healers—play critical roles in underserved areas but may not be integrated into formal vaccination programs. Their exclusion perpetuates inequities, leaving them susceptible to Hepatitis B and heightening transmission risks. Justice and fairness demand equal vaccine access for all healthcare workers, regardless of employment status [59].

Ethical policies must actively include and support these groups through targeted outreach, workplace or community-based vaccination, and accessible education campaigns. Exclusion not only increases health risks but also fosters feelings of discrimination, lowering morale, job satisfaction, and retention [113-120]. Ultimately, vaccination policies should be grounded in equity, ensuring fair access for all healthcare workers. Addressing the needs of marginalized groups is both an ethical obligation and a public health necessity, promoting justice, inclusion, and workforce protection [119-120].

Informed Consent and Autonomy

Informed consent is a cornerstone of medical ethics and human rights, emphasizing the importance of individual autonomy in healthcare decisions [120]. Autonomy, in this context, refers to the right of individuals to make informed and voluntary choices about their healthcare, free from coercion or undue influence. This ethical principle plays a central role in discussions around mandatory vaccination policies for healthcare workers, particularly in sub-Saharan Africa, where healthcare systems often face unique challenges [121]. The implementation of such policies must balance the need to protect public health and the health of healthcare workers with respect for individual autonomy [122-124]. The tension between public health imperatives and personal freedom can be a complex issue, and this complexity is particularly evident when discussing the ethical implications of mandatory vaccination.

Mandatory Policies vs. Voluntary Uptake

Mandatory vaccination policies raise ethical concerns about autonomy, particularly in contexts where personal choice is considered a fundamental right [125]. Compulsory Hepatitis B vaccination for healthcare workers requires weighing the benefits of immunization against potential infringements on freedom [70]. The dilemma centers on whether individual autonomy can be restricted to safeguard patients, colleagues, and the broader community [62]. Given the high risk of transmission in healthcare settings, beneficence and non-maleficence support mandates as a way to reduce harm [59]. Yet, challenges remain in balancing collective protection with respect for autonomy, especially amid vaccine hesitancy or concerns about safety [64].

Voluntary uptake emphasizes informed choice, respecting healthcare workers’ autonomy while allowing decisions based on beliefs and risk perceptions. However, voluntary strategies may yield lower coverage, particularly in the presence of misinformation or skepticism, threatening both worker and patient safety [63-65]. This highlights the ethical tension between respecting autonomy and meeting collective health obligations.

A balanced approach is needed: while autonomy should not be dismissed without strong justification, the elevated risks in healthcare settings provide grounds for mandates [60]. Policies may also adopt middle-ground solutions—strongly encouraging vaccination while allowing limited exemptions under conditions that do not compromise public health [59].

Education and Awareness Campaigns

Ethical strategies to balance mandatory vaccination with healthcare workers’ autonomy require robust education and awareness campaigns [125-127]. These campaigns provide accurate information on vaccine safety, efficacy, and the risks of Hepatitis B, empowering healthcare workers to make informed decisions based on evidence rather than misconceptions [128-132]. Trust and transparency are central, with a duty to communicate both benefits and risks clearly [133-135]. Addressing vaccine hesitancy is critical, particularly fears about side effects or limited knowledge of vaccine development. Campaigns should foster open dialogue between healthcare workers and medical experts, creating opportunities to raise concerns and strengthen trust [135]. Education must also be continuous, offering updates through workshops, seminars, and online resources, thereby reinforcing vaccination’s importance and cultivating a culture of immunization [132-135].

From an ethical perspective, education campaigns must avoid coercion and respect autonomy. Information should be unbiased and balanced, allowing healthcare workers the space to decide freely. At the same time, campaigns should highlight professional responsibilities, emphasizing healthcare workers’ duty to protect patients and colleagues from Hepatitis B [62,40]. By promoting informed choice while underscoring collective responsibility, education campaigns can ethically strengthen vaccination uptake and support public health goals.

Public Perception and Trust

Public perception and trust play a pivotal role in the successful implementation of healthcare policies, particularly in the context of mandatory vaccination programs. In the case of the Hepatitis B vaccination for healthcare workers in sub-Saharan Africa, building trust among healthcare professionals and the wider public is essential for achieving high vaccine uptake. The ethical challenges surrounding public perception and trust are multifaceted and require thoughtful engagement with healthcare workers, transparency, and effective communication strategies to ensure that policies are not only accepted but embraced by those they aim to protect [130]. Understanding how healthcare workers perceive mandatory vaccination policies and the factors that influence their trust in vaccines is crucial for the success of these initiatives.

Ethical Strategies for Policy Acceptance

One of the most critical ethical strategies for ensuring the acceptance of mandatory vaccination policies is engaging healthcare workers in the development of these policies. This approach ensures that the perspectives, concerns, and needs of healthcare professionals are considered in the policymaking process, which can help foster a sense of ownership and trust in the policy [136-137]. Engaging healthcare workers in the development of vaccination policies can be done through consultations, focus groups, and collaborative decision-making processes. When healthcare workers are part of the process, they are more likely to feel that their autonomy is respected, and their professional expertise is valued, which can increase their acceptance of the policy.

Incorporating the views of healthcare workers into the policy development process also serves to identify potential challenges or areas of concern that might arise during implementation. These may include logistical issues, such as the availability of vaccines, or ethical concerns, such as the impact on personal freedoms and individual autonomy. By addressing these concerns early on, policymakers can craft policies that are not only practical but also ethically sound and more likely to be embraced by healthcare workers [138]. Furthermore, such engagement can provide opportunities to educate healthcare workers about the benefits of vaccination and how these policies align with the overarching goal of protecting both their health and that of their patients. This collaborative approach helps build trust, reduces resistance, and ensures that the policy reflects the values and priorities of the healthcare workforce [139].

An essential component of engaging healthcare workers in policy development is ensuring transparency throughout the process. Transparency in policy development involves clear communication about the rationale for mandatory vaccination, the evidence supporting its effectiveness, and the potential benefits and risks [140]. When healthcare workers understand why certain decisions are made and how these decisions align with broader public health goals, they are more likely to trust the policy and support its implementation. Transparency also involves the acknowledgment of challenges and the willingness to address concerns raised by healthcare workers. Ethical strategies for policy acceptance therefore emphasize not only the importance of involvement but also the need for honesty, openness, and responsiveness to concerns [141-142].

Additionally, ethical strategies for policy acceptance should aim to create a dialogue between healthcare workers and the broader public [141-142]. Engaging in open communication about the policy's benefits and the reasons behind its implementation can help mitigate potential misunderstandings and foster trust in the healthcare system as a whole. In settings where healthcare workers serve as trusted figures in their communities, their acceptance of mandatory vaccination policies can positively influence public perceptions of the vaccine, contributing to broader vaccine acceptance [142-143].

Addressing Vaccine Hesitancy

Vaccine hesitancy among healthcare workers poses a significant ethical challenge in implementing vaccination policies [144-145]. Despite their proximity to medical knowledge, some healthcare workers harbor doubts about vaccine safety and efficacy [146-147]. These concerns may stem from misinformation, past negative experiences, or skepticism about the motives behind vaccination programs. Addressing hesitancy requires respecting autonomy while safeguarding public health.

A major ethical issue is misinformation, which spreads rapidly through social media and other networks [148]. False claims about risks or vaccine development can erode confidence, even among healthcare workers. This creates a dilemma: how to counter misinformation without infringing on autonomy or creating distrust [148-150]. An ethical response involves providing accurate, evidence-based, and accessible information [59]. Campaigns should explain both benefits and risks while addressing emotional concerns such as fear of side effects [138-139]. Open dialogue and transparency are crucial for reassurance.

Trust is equally important. Healthcare workers are more receptive when they believe vaccination policies are grounded in sound public health principles [151-153]. Tackling root causes of distrust such as government overreach, inequities, or skepticism of pharmaceutical companies, through transparency and engagement with trusted figures is vital. Addressing hesitancy requires balancing autonomy and collective responsibility. Through education, informed consent, and trust-building, policies can enhance uptake and protect both healthcare workers and patients [62-153].

Table 1: Ethical Principles Guiding Mandatory Hepatitis B Vaccination Policies for Healthcare Workers in Sub-Saharan Africa

Sustainability and health system considerations are critical in the effective implementation of mandatory vaccination policies, particularly in resource-constrained regions like sub-Saharan Africa. The long-term success of these policies depends not only on the immediate availability and uptake of vaccines but also on the broader integration of vaccination initiatives within the healthcare system [154]. Ethical concerns related to sustainability are intertwined with considerations of equity, accessibility, and the long-term impact on both the healthcare workforce and the general population. Addressing these concerns requires a holistic approach that ensures that policies are not only effective in the short term but also maintain their viability and ethical soundness over time [154-155].

Long-Term Vaccine Supply

One of the most pressing ethical concerns in the context of mandatory vaccination policies for healthcare workers is the long-term availability of vaccines [99-104]. For a vaccination policy to be effective, it must be sustained over time, ensuring that the vaccine is continuously available to all healthcare workers who require it. This presents several ethical challenges, particularly in low-resource settings where healthcare infrastructure may be fragile, and access to vaccines can be inconsistent. Ensuring that there is a reliable and ongoing supply of the Hepatitis B vaccine is crucial, as interruptions in vaccine availability can undermine public confidence in the policy and result in uneven vaccine uptake [99].

The ethical issue of vaccine supply encompasses several dimensions. First, there is the challenge of procurement. In many sub-Saharan African countries, the procurement of vaccines is heavily dependent on international aid, donor funding, and bilateral agreements [156-157]. While these sources of funding are essential, they can also be unstable and subject to political or economic fluctuations, creating a potential risk to the long-term availability of vaccines [157]. This raises ethical concerns about the fairness of vaccine distribution and the potential for marginalized groups, such as rural healthcare workers, to be excluded from vaccination programs if vaccine supply is inconsistent or if priority is given to urban or more affluent areas.

Additionally, maintaining a long-term vaccine supply requires significant investment in local healthcare infrastructure [156]. Ethically, it is important to ensure that vaccine storage, transportation, and distribution systems are developed in a way that guarantees equitable access for all healthcare workers, regardless of their location or socioeconomic status. This means addressing logistical challenges such as maintaining cold chain requirements, which are particularly challenging in areas with poor electricity infrastructure. The provision of vaccines should be done in a way that is sustainable, both in terms of economic costs and health outcomes, and it should be accompanied by support for the local healthcare system to ensure that vaccines are administered safely and effectively [157].

Ethical considerations around vaccine supply also involve issues of equity and justice. In the context of mandatory vaccination, it is essential to ensure that vaccines are available to all healthcare workers without discrimination. This includes addressing disparities in access between public and private healthcare workers, as well as between urban and rural healthcare workers [157]. A sustainable vaccine supply must be equitable, ensuring that no healthcare worker is left behind due to geographical, economic, or political barriers. Failure to address these disparities would not only undermine the effectiveness of the vaccination program but also violate ethical principles of fairness and justice.

Integration with Broader Occupational Health Policies

The effectiveness of mandatory vaccination policies for healthcare workers depends on how well they are integrated with broader occupational health measures. Ethical alignment with workplace safety policies ensures a comprehensive approach to worker protection, which typically includes PPE, safety training, and health screenings [158]. When viewed in isolation, mandatory vaccination may appear incomplete or coercive, undermining trust in both the healthcare system and authorities. Instead, vaccination should be positioned as one component of a holistic occupational safety strategy.

Healthcare workers face diverse risks such as infectious diseases such as Hepatitis B, hazardous exposures, and the physical and psychological demands of their jobs [1-5]. A robust occupational health framework should therefore address not only disease prevention but also mental health support, adequate PPE, fair compensation, and improved working conditions [158]. Aligning vaccination with these measures demonstrates respect for worker dignity and autonomy, avoiding perceptions of punitive or stand-alone interventions [59].

Integration also requires grounding policies in evidence and best practices, while accommodating diverse worker needs, such as medical contraindications or vaccine concerns. Sustainability is equally critical: secure vaccine supply, equitable distribution, and systemic support are essential. By embedding vaccination within a broader occupational health framework, policymakers can advance a more ethical, effective, and sustainable strategy for protecting healthcare workers and public health [158].

Policy Recommendations and Ethical Frameworks

In the context of mandatory vaccination policies for healthcare workers in sub-Saharan Africa, it is essential to develop policies that are not only effective but also ethically sound, sustainable, and adaptable to local conditions [40]. These policies must be crafted with an understanding of the unique challenges and opportunities that exist within each context, while ensuring that they align with core ethical principles. Developing such policies requires a careful balance between public health goals, individual rights, and the overarching need for equity and justice. To this end, the policy recommendations provided here focus on the creation of context-sensitive policies and the establishment of robust governance structures that promote accountability, transparency, and fairness [59-61].

Developing Context-Sensitive Policies

A key consideration in the development of ethical and sustainable mandatory vaccination policies is the recognition that sub-Saharan Africa is a diverse region with varying healthcare systems, economic capacities, cultural practices, and public health challenges [143]. Therefore, policies should be tailored to the specific needs, resources, and realities of individual countries or even regions within countries. A one-size-fits-all approach may be ineffective or ethically problematic, particularly when it comes to vulnerable populations such as healthcare workers in rural or underserved areas [136]. To develop context-sensitive policies, the first step is to conduct a thorough assessment of the local healthcare infrastructure, vaccine supply chains, and the specific risks faced by healthcare workers in each setting. This assessment should be inclusive, engaging both healthcare workers and local communities to understand their concerns, priorities, and barriers to vaccine uptake. By involving stakeholders in the policy development process, policymakers can ensure that the resulting policy reflects local realities and is more likely to be accepted and effective [143].

In addition, the ethical principles of equity and justice must be at the forefront of policy development. In sub-Saharan Africa, disparities in healthcare access, especially between urban and rural areas, are widespread [159-163]. Therefore, it is critical to design policies that ensure equitable access to vaccines for healthcare workers across all regions, including remote and rural settings. This may involve making special provisions for mobile vaccine clinics, transportation of vaccines, or outreach programs that specifically target hard-to-reach healthcare workers. A policy that fails to address these disparities would risk exacerbating existing inequalities, which would be ethically unacceptable. Context-sensitive policies must also take into account the socio-cultural context in which healthcare workers operate. Vaccine hesitancy is a significant challenge in many African countries, often driven by misinformation, mistrust of medical authorities, and cultural beliefs. Policies should include targeted education and awareness campaigns that are culturally sensitive and informed by local beliefs and practices. Engaging community leaders, respected healthcare professionals, and influencers in these campaigns can help build trust and encourage acceptance of vaccination [142].

Moreover, the sustainability of these policies depends on aligning them with broader public health strategies. Policies that focus solely on vaccination without considering other occupational health measures may be ineffective. Therefore, mandatory vaccination policies should be integrated into comprehensive healthcare worker protection strategies that include personal protective equipment (PPE), mental health support, and regular health screenings. Such integration will not only improve vaccine uptake but also enhance the overall safety and well-being of healthcare workers [158].

Building Ethical Governance Structures

The success of mandatory vaccination policies depends not only on their content but also on the governance systems that enforce and monitor them. Ethical governance structures ensure fairness, transparency, and respect for healthcare workers’ rights, thereby building trust and minimizing potential abuses [164]. Clear and transparent enforcement processes must define roles across healthcare systems, supported by guidelines that outline vaccination criteria and compliance monitoring [114-115]. Accountability requires consistent, non-discriminatory enforcement, with sanctions for non-compliance balanced by accommodations for legitimate barriers such as medical contraindications or religious objections [134].

Robust monitoring, regular audits, and feedback loops are essential for evaluating policy impact and maintaining accountability. Independent oversight bodies or ethics committees can provide avenues for grievances and strengthen confidence in the policy. Finally, adaptability to supply disruptions or new evidence, coupled with transparent communication and education, ensures policies remain ethical, effective, and context-sensitive for healthcare workers across sub-Saharan Africa.

Implementing mandatory Hepatitis B vaccination for healthcare workers in sub-Saharan Africa requires policies that are ethically grounded yet tailored to regional realities. First, governments should ensure equitable vaccine access by strengthening distribution systems, particularly in rural and underserved areas. Mobile vaccination units, workplace-based campaigns, and partnerships with local health centers can address logistical barriers. Second, cost should not be a deterrent. Subsidizing or fully funding the vaccine for healthcare workers, including those in private and faith-based facilities, is critical to achieving fairness and compliance. This financial support can be complemented by incentives such as certification, career advancement, or recognition programs for vaccinated staff.

Third, participatory governance should be embedded in policy design. Engaging healthcare workers in consultations, policy formulation, and feedback mechanisms fosters ownership and reduces resistance. Transparent communication that emphasizes vaccine safety, effectiveness, and long-term protection against occupational risk is essential to counter misinformation. Fourth, governments must prioritize monitoring and accountability. Establishing independent oversight committees to track coverage rates, address grievances, and adapt strategies ensures fairness and legitimacy. Ultimately, mandatory vaccination policies must balance public health protection with equity, trust, and inclusivity, transforming compliance into a shared responsibility across sub-Saharan African health systems.

Future Research Directions

Despite the significant insights provided by this review, several gaps in knowledge remain, and further research is needed to address these issues comprehensively. First, there is a need for more empirical studies that assess the real-world impact of mandatory vaccination policies on healthcare workers’ compliance, job satisfaction, and morale. Understanding the psychosocial effects of such policies will be crucial in crafting more effective and ethically acceptable strategies for vaccine uptake.

Additionally, research is needed to explore the role of cultural beliefs and community engagement in the acceptance of vaccination policies. In sub-Saharan Africa, vaccine hesitancy remains a challenge, often rooted in mistrust of health authorities and traditional beliefs. Further exploration of culturally tailored educational campaigns and community-based approaches to vaccine promotion is essential for overcoming these barriers and ensuring the success of mandatory vaccination programs.

Finally, future research should also investigate the long-term sustainability of vaccination programs in resource-limited settings. While mandatory vaccination policies can be effective in the short term, their success in the long run will depend on the availability and distribution of vaccines, as well as the integration of vaccination policies with broader healthcare worker protection strategies. Research on the supply chain logistics, financing, and public-private partnerships required to ensure consistent vaccine availability will be crucial in maintaining the sustainability of these programs.

Call to Action

As this review has demonstrated, the ethical challenges associated with mandatory Hepatitis B vaccination policies for healthcare workers are significant but not insurmountable. Policymakers must be proactive in developing policies that are not only grounded in sound public health principles but also respectful of the rights and needs of healthcare workers. The ethical foundations of such policies must be rooted in the values of justice, equity, transparency [59-62], and respect for autonomy, ensuring that healthcare workers are not only protected from occupational risks but also treated with dignity and fairness. Advocating for ethically sound and equitable vaccination policies is not only a matter of public health but also a matter of social justice. Ensuring that all healthcare workers, regardless of their location or socioeconomic status, have access to life-saving vaccines is an ethical imperative. At the same time, policies must be designed with sensitivity to the unique challenges faced by healthcare workers in different settings, particularly in resource-limited environments where logistical, financial, and cultural barriers may hinder vaccine uptake.

The ethical considerations surrounding the implementation of mandatory Hepatitis B vaccination policies for healthcare workers in sub-Saharan Africa are multifaceted and require careful attention to the principles of justice, equity, autonomy, and public health. This review has explored these dimensions, focusing on the challenges and ethical dilemmas that policymakers face when balancing the protection of public health with the rights and freedoms of healthcare workers. The discussions have highlighted the importance of context-sensitive policy design, transparent governance structures, and the need for equitable access to vaccines, all of which are essential to ensuring the success and ethical soundness of vaccination initiatives

This review highlights the enduring tension between protecting public health and respecting individual autonomy, particularly in health systems marked by inequality. While mandatory Hepatitis B vaccination for healthcare workers can be ethically justified, its effectiveness depends on policies that go beyond compliance to build trust, inclusivity, and shared responsibility. A key insight is the need for participatory governance, where healthcare workers are actively involved in policy design, implementation, and monitoring. Transparent communication, informed consent, and efforts to counter misinformation are equally vital in fostering trust. Another critical point is addressing systemic inequities in vaccine access. Mandates without equitable distribution risk deepening disparities; thus, policies must integrate logistical support such as mobile clinics, outreach, and incentives for underserved areas. Finally, vaccination frameworks must remain dynamic and accountable, supported by continuous monitoring, feedback mechanisms, and independent oversight. By embedding participation, equity, and adaptability, policymakers can create ethically grounded and sustainable vaccination policies that not only curb Hepatitis B but also strengthen health systems and set a precedent for future public health interventions.

Contributions of the Authors

SOA, AIA, and YBN conceptualized this study. All authors conducted a literature search to put together relevant studies. All authors wrote the initial draft, which SOA and AIA edited. SOA is the corresponding author and is responsible for the work’s credibility.

This study did not receive any specific funding from public, commercial, or not-for-profit sectors.

The authors declare that they have no competing interests.

Not applicable.

Consent for publication

Not applicable.

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Clinical Trial Number

Not Applicable

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