Vaccine hesitancy and healthcare providers

While most peoplevaccinate according to the recommended schedule, this success is challenged by individuals and groups who delay or refuse vaccines. The aim of this article is to review studies on vaccine hesitancy among healthcare providers (HCPs), and the influences of their own vaccine confidence and vaccination behaviour on their vaccination recommendations to others.

The search strategy was developed in Medline and then adapted across several multidisciplinary mainstream databases including Embase Classic & Embase, and PschInfo. All foreign language articles were included if the abstract was available in English.

A total of 185 articles were included in the literature review. 66% studied the vaccine hesitancy among HCPs, 17% analysed concerns, attitudes and/or behaviour of HCPs towards vaccinating others, and 9% were about evaluating intervention(s). Overall, knowledge about particular vaccines, their efficacy and safety, helped to build HCPs own confidence in vaccines and their willingness to recommend vaccines to others. The importance of societal endorsement and support from colleagues was also reported.

In the face of emerging vaccine hesitancy, HCPs still remain the most trusted advisor and influencer of vaccination decisions. The capacity and confidence of HCPs, though, are stretched as they are faced with time constraints, increased workload and limited resources, and often have inadequate information or training support to address parents’ questions. Overall, HCPs need more support to manage the quickly evolving vaccine environment as well as changing public, especially those who are reluctant or refuse vaccination. Some recommended strategies included strengthening trust between HCPs, health authorities and policymakers, through more shared involvement in the establishment of vaccine recommendations.

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Abbreviations
GPgeneral practitionerHCPhealthcare providerHPVhuman papillomavirusMMRmeasles mumps and rubellaSAGEStrategic Advisory Group of Experts on Immunisation
Keywords
Vaccine hesitancyHealthcare providerVaccination
1. Introduction
Vaccination is often cited as one of the most effective ways of controlling infectious diseases [1]. However, while most people vaccinate according to the recommended schedule, this success is being challenged by individuals and groups who choose to delay or refuse vaccines [2]. Examples of reluctant individuals include parents delaying vaccinations for their infant, teenagers (or their parents) who choose not to vaccinate against human papillomavirus (HPV), pregnant women deciding not to vaccinate against flu or pertussis, the elderly choosing not to vaccinate against flu or shingles, and even HCPs not vaccinating against influenza.

Over recent decades, some patients have become more critical about healthcare advice and some resist (or are hesitant to accept) recommended vaccinations. HCPs have had different responses to this changing environment. Some practices have dropped patients if they refuse vaccination [3], [4] making the case that it puts their other patients at risk, while in other practices, some physicians agree to delay vaccination or administer partial doses, in order to protect the trust relationship with their patient, although recognising there is no clinical evidence to support such an approach [5].

The vaccination decision-making process includes people who agree to be vaccinated immediately, because they see it as the norm, and those that take their time weighing up the pros and cons of vaccination, talking with family, friends or members of their community, searching the internet, and asking their HCP for advice. The importance of HCP’s vaccine recommendations in the decision making process has been well documented [6]. HCPs are one of the strongest influencers in vaccination decisions. In a study in six European countries, the general practitioner (GP), pharmacy and local hospital were listed as being the most trustworthy sources of health alerts or information about medicines [7]. However, there are some HCPs who feel ill-equipped to answer questions or engage in difficult conversations with those who are reluctant to be vaccinated.

There is a growing body of literature on the issue of vaccine hesitancy, with the most important reasons identified varying by country, region, sub-population, vaccine, and contextual influences. Despite variations in reasons for hesitancy across geographies and vaccines, there are common themes that emerge globally [2], [8]. The World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) on Immunisation convened a working group to investigate the nature and scope of vaccine hesitancy and they have created a model of determinants of vaccine hesitancy organised around three domains: 1. ‘Contextual influences’; 2. ‘Individual/social group influences’; and 3. ‘Vaccine and vaccination-specific issues’ [2]. All three domains include the influence of others on vaccine hesitancy: Domain (1) ‘Contextual influences’ includes influential leaders and individuals; domain, (2) ‘Individual/social group influences’ includes personal experience with and trust in health system and provider; and domain, (3) ‘Vaccine and vaccination-specific issues’ includes the role of healthcare professionals.

Given the documented importance of HCPs’ influence in the decision of their patients to be vaccinated, the aim of this literature review is to explore existing research specifically on vaccine hesitancy among HCPs, and consider the influences of HCPs’ own vaccine confidence and behaviours on their vaccination recommendations to others.

2. Methods
2.1. Search strategy and selection criteria
The search strategy was developed in Medline and then adapted as required by differential indexing across several multidisciplinary mainstream databases including Embase Classic & Embase, and PschInfo. The strategy included an extensive list of keywords (Table 1). The search was run across all databases on 26th October 2015.