Pauline Paterson
François Meurice
Steffen Glismann
Susan L. Rosenthal
Heidi J. Larson
Publication Date
October 31, 2016

London School of Hygiene & Tropical Medicine (Paterson, Larson); GSK Vaccines (Meurice, Glismann); Columbia University College of Physicians and Surgeons and New York-Presbyterian/Morgan Stanley Children's Hospital (Stanberry, Rosenthal); Department of Global Health, University of Washington (Larson)

"While the findings of the literature review reported on in this paper were largely specific to HCPs' individual vaccine hesitancy or confidence and its influence on patient recommendations, that dyadic relationship is one small, albeit critical link in a much larger trust chain that needs attention and support."

In the face of emerging vaccine hesitancy, it has been found that healthcare providers (HCPs) continue to be 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 they often have inadequate information or training support to address parents' questions. This article reviews 185 peer-reviewed studies on vaccine hesitancy among HCPs and the influences of their own vaccine confidence and vaccination behaviour on their vaccination recommendations to others.

As the authors explain, the vaccination decision-making process includes people who agree to be vaccinated immediately, because they see it as the norm, and those who 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.

Of the 185 articles analysed, 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) to increase vaccine uptake by HCPs.

Among the publications on HCPs' vaccination behaviour (n = 140), several identified that HCPs were more likely to recommend vaccination if they were themselves vaccinated. However, some HCPs expressed a clear view that their own vaccination behaviour is their own choice, as is the choice of their patient.

Overall, the literature indicates that knowledge about particular vaccines and their efficacy and safety helped to build HCPs own confidence in vaccines and their willingness to recommend vaccines to others. However, more support is needed, especially for managing difficult conversations with a vaccine-reluctant patient or parent. Studies with different HCP groups in multiple settings identified a lack of preparedness for advising patients about vaccination and a lack of training as inhibiting factors for recommending the vaccine. Finally, concerns about increased workload and limited resources were seen as obstacles to engaging patients on vaccine hesitancy. The importance of societal endorsement and support from colleagues was also reported to be factors contributing to HCP confidence and willingness to recommend vaccination.

In terms of interventions to increase vaccine uptake by HCPs, the information campaigns evaluated varied from education courses, talks or meetings, to posters, individual letters or emails, or hospital webpages. One multi-hospital, multi-intervention study identified the following factors to be associated with higher vaccination rates of HCPs: weekend provision of vaccine, train-the-trainer programmes, report of vaccination rates to administrators or to the board of trustees, a letter sent to employees emphasising the importance of vaccination, and any form of visible leadership support.

Figure 3 in the article summarises the findings from this review. It is organised around - yet is an adaptation of - the World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) on Immunisation's model of determinants of vaccine hesitancy, which is organised around 3 domains: (i) contextual influences, which includes influential leaders and individuals; (ii) individual/social group influences, which includes personal experience with and trust in health system and provider; and (iii) vaccine and vaccination-specific issues, which includes the role of healthcare professionals.

In discussing the findings, the authors observe that there is a growing number of studies investigating the vaccination decision-outcomes of different HCP approaches to discussing vaccination with their patients. One study in the United States (US), for example, found that how providers initiate the vaccine recommendation is an important determinant of vaccine acceptance. Parents had significantly higher odds of accepting a vaccine if the provider initiated a consultation using a presumptive approach (e.g., "Today we're going to be vaccinating your child with..."), which projected more confidence about vaccination than when they opened the conversation with a statement that was aiming to be engaging (e.g., "How do you feel about vaccination?"), but suggested that the provider was uncertain. The presumptive approach did not exclude the opportunity for a dialogue with the patient, but started the conversation with a more positive tone about vaccination. The authors call for more studies such as this in other settings to validate this finding.

In addition to identifying the need for more training or information support on vaccine risks and benefits, as noted above, the authors cite Verger et al., who underline the importance of designing and evaluating communication tools for HCPs so that they are able to engage in difficult discussions with patients reluctant about vaccination. One point that emerged in their proposed actions is the importance of strengthening trust between the HCPs and the health authorities. One step towards this would be more involvement by HCPs in some of the decision-making around the vaccination recommendations and policies that they are in the front lines to deliver on. In another paper, Yaqub and colleagues also stress the importance of building trust in - and within - institutions, particularly pointing to the trust and support relationship needed between the policymakers and the HCPs, to ultimately build the trust of the public. In addition, they propose a sentinel network to pick up emerging vaccine concerns and trends in order to help HCPs have better advance information on the types of questions they might face.

In conclusion: "HCPs need more support to manage the changing public as well as quickly evolving vaccine environment."