Healthcare Workers' Perceptions and Experiences of Communicating with People over 50 Years of Age about Vaccination: A Qualitative Evidence Synthesis

"It is important that healthcare workers consider each individual's needs, views, and levels of understanding, and tailor information about vaccination accordingly. They also need to communicate this information in a way that is accessible. To have these skills requires training, support, time, opportunity and self-awareness."

The prevention of infectious diseases, including seasonal influenza, pneumococcal diseases, herpes zoster (shingles), and COVID-19, through immunisation can support healthy ageing. Older adults may also benefit from booster doses of vaccines for pertussis, diphtheria, tetanus, and polio. Communication with healthcare workers can play an important role in older people's decision to vaccinate. The aim of this Cochrane systematic review was to explore healthcare workers' perceptions and experiences of communicating with older adults about vaccination. The review is part of a European Union (EU)-funded project entitled VITAL (Vaccines and InfecTious diseases in the Ageing popuLation) that aims to develop strategies to train and educate healthcare workers about vaccines and vaccination communication for older adults.

With a focus on studies published up to March 21 2020 (before COVID-19 vaccines were available), the researchers searched for and analysed relevant qualitative studies. The 11 studies that met inclusion criteria were published between 2007 and 2019 in English; all studies were from high-income countries. Notably, only one of the articles focused specifically on communication between healthcare workers and older adults about vaccination. "The apparent lack of attention paid by researchers to this topic may reflect a general lack of acknowledgement of communication as an intervention that can be studied in and of itself."

The researchers used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess confidence in each review finding. For example, a few of the findings in which they have moderate confidence are:

• When the topic of vaccination was discussed, healthcare workers described a lack of information and presence of misinformation, fears, and concerns about vaccines among older adults.
• The manner in which healthcare workers discussed vaccines with older adults appeared to be linked to what they saw as the aim of vaccination communication. Some healthcare workers thought it was important to provide information but emphasised the right and responsibility of older adults to decide for themselves. Other healthcare workers used information to persuade and convince older adults to vaccinate. Still others tailored their approach to what they believed the older adult needed or wanted.
• Not all healthcare workers were convinced of the effectiveness of vaccines for older adults and emphasised the importance of evidence about benefits and harms.
• Healthcare workers did not always prioritise vaccination services for older adults when faced with limited time and other, more acute health issues.

Considering all the findings, the researchers offer questions for consideration that may have implications for practice - noting that the relevance of these questions to each setting may vary. In brief:

1. Communication aim: Have the authorities in your setting made it clear what they see as the aim of vaccination communication with older adults and what the older adult's role in the decision-making process should be?
2. Older adults' rights and preferences: where the overall aim of communication is to support informed decisions, do healthcare workers acknowledge and respect the older adult's right to information and the right to make his or her own decision? Do healthcare workers acknowledge that older adults may want different quantities of information, may not want to make the decision themselves, or may lack the capacity to do so?
3. Communication training: Have healthcare workers been provided with appropriate initial and ongoing training in communication or shared decision-making skills, or both? Does this training reinforce the message that healthcare workers should avoid introducing their own criteria for determining who should and should not receive vaccines?
4. Awareness around influence: Are healthcare workers aware of the influence they may have on older adults' decisions and how they use this influence? Can this influence be used positively to create an atmosphere of trust that supports good communication, rather than simply a tool to persuade older adults to be compliant?
5. Healthcare workers' vaccine uptake: Are healthcare workers who have been offered a vaccine themselves but have declined it still willing to offer neutral and balanced information to older adults about a vaccine?
6. Part of healthcare workers' role? Do healthcare workers regard communication about vaccination as part of their role? Is this role made clear in their professional education and through regulations and job descriptions?
7. Established relationship? Do older adults already have an established relationship with a particular healthcare worker that may increase trust in communication? If so, is that healthcare worker involved in communication with older adults regarding vaccination?
8. Initiating the conversation: Is it part of the healthcare worker's responsibility, rather than that of the older adults, to raise the issue of vaccination, and has this responsibility been made part of a routine in clinical practice?
9. Supporting vulnerable older adults: Do healthcare workers have guidance and support when communicating with older adults who do not have the capacity to make their own decisions?
10. Language issues: Do healthcare workers have guidance and support when communicating with older adults who do not speak the majority language in their setting?
11. Time: Do healthcare workers have sufficient time to discuss vaccine-related issues with older adults?
12. Context: Are healthcare workers offering vaccine services opportunistically (for instance, when attending appointments about other healthcare issues) or at designated timepoints (for instance, during vaccination days), and what implications does this have for communication? For instance, will there be time to send information beforehand so that the older adult is sufficiently prepared to be able to make a decision?
13. Disease information: Do healthcare workers have a good understanding of the disease that the vaccine is intended to prevent, particularly if this is a disease they are not likely to see in their own practice? Do they have easy access to up-to-date information about its severity and its prevalence in their setting? Is this information provided in ways they can share easily with older adults?
14. Addressing key concerns: Do healthcare workers have easy access to up-to-date, evidence-based information that addresses the questions, fears, and concerns about vaccines that older adults commonly have in their setting? Is this information provided in ways they can share easily with older adults?
15. Vaccine information: Do healthcare workers have easy access to up-to-date, evidence-based information about the effectiveness of the vaccine and potential adverse effects? Is this information provided in ways they can share easily with older adults?
16. Patient data: Do healthcare workers have easy access to the patient information they need when discussing vaccines with an older adult or making a recommendation? Where the person's age is not the only indicator but where other underlying health conditions also play a role, do they have easy access to the person's medical data?
17. Agreement with recommendations: Do healthcare workers support current recommendations about who should receive the vaccine?

Considerations/suggestions for future research(ers) include:

• Be explicit about the motivations driving research (e.g., to increase vaccine uptake, support informed choice, etc.), and consider the extent to which researchers' own perspectives, places of work, or sources of funding have influenced the aim, design, and conduct of their research.
• Conduct more primary research on vaccine decision-making and communication about vaccines between healthcare workers and older adults (e.g., in nursing home settings, in situations where decision-making capacity is in question, etc.).
• Conduct more primary research in a broader range of settings, including low- and middle-income settings.
• Explore the influence of demographic factors, including age, gender, ethnic background, income, and education level, on communication between healthcare workers and older adults.
• Collect data through participant or non-participant observation in order to explore healthcare worker practice.
• Study communication with older adults about vaccines developed in the context of a pandemic (e.g., COVID-19), and compare the nature of this communication to communication around other vaccines.
• Improve the quality of reporting to enable others to learn how to replicate the interventions described in trials on vaccine communication on older adults.
• Consider using/adapting other taxonomies that are available, such as the COMMVAC taxonomy of communication interventions for childhood vaccination or the TIDieR (Template for Intervention Description and Replication) checklist.