Healthcare Providers' Vaccine Perceptions, Hesitancy, and Recommendation to Patients: A Systematic Review

"Improving HCP [healthcare provider] knowledge and assuring their access to information they deem trustworthy are essential to supporting HCPs' role as 'trusted messengers' to promote vaccine acceptance."

Evidence shows that the communication and behaviour of healthcare providers (HCPs) influence patient receptivity to and uptake of vaccines, consistent across populations and type of vaccine. This systematic review compares and synthesises peer-reviewed studies on (i) HCP perceptions, knowledge, and reservations regarding vaccination and (ii) how their vaccine attitudes manifest in their behaviour, including recommendations and uptake. The study also identifies variations across HCP subgroups and different vaccines to inform research and practice.

Primary research studies published in English at any point until September 16 2020 were searched in PubMed, Web of Science, Embase, CINAHL, and PsycINFO. Included studies focused on HCP opinions, knowledge, hesitancy, or practice relating to any vaccine and analysed the influence on their communication with or recommendation to patients. In total, 96 papers from 34 countries were included, covering 17 vaccines. A majority were quantitative studies conducted via email or online with HCPs; four utilised qualitative interviews and mixed methods. A small number referenced extant models as research framework; most of these developed questionnaires based on the Health Belief Model and Theory of Planned Behavior, and one built upon the Cognitive Model of Empowerment.

Key findings:

• HCP attitudes, perceptions, and knowledge - HCP vaccination attitudes and practices varied across specialties, vaccines, and countries; demographic impact was inconclusive. There was ample evidence that HCPs' attitudes toward vaccines influenced their recommendation practices across specialties. HCPs who believed administering vaccination and advising patients about vaccines were their responsibility had increased recommendation, discussed vaccines more often, and perceived greater vaccine utility. Recommendation was positively associated with provider knowledge and experience, beliefs about disease risk, and perceptions of vaccine safety, necessity, and efficacy. Having sufficient and reliable information supported vaccine advocacy. Self-uptake can also be a predictor of recommendation; for example, HCPs who received or planned to receive the influenza vaccine were 2.8-8 times more likely to recommend it. Furthermore, providers who did not vaccinate their own children were less likely to either receive or recommend vaccines. Logistical barriers such as lack of time had a negative effect.
• Patient and contextual factors - Patient/parent or other provider refusal of vaccines and perceptions of their resistance impacted HCPs' vaccination practices; recommendation rates were higher amongst HCPs who anticipated such concerns, expected patient compliance, and did not believe parents would reject the vaccine. HCPs who followed, consulted, or were aware of guidelines were more likely to advocate for vaccines. HCPs who trusted information from institutional sources had lower hesitancy and recommended vaccination more frequently. Seeking information from official sources was positively associated with recommending vaccines, but non-recommenders often consulted news media, the internet, magazines, and pharmaceutical companies.
• Human papillomavirus (HPV)-specific behaviour - HPV vaccines were more often recommended to older, female adolescents. Reasons cited for not discussing or recommending vaccines included HCPs' discomfort initiating conversations around sex or sexually transmitted infections, awareness that patients were not sexually active, belief that discussion would increase risky sexual activity, and infrequent patient care visits.

In short, though HCPs have been identified as potentially "vital advocates for patients and the public,...studies indicated a prevalence of provider hesitancy pertaining to inadequate knowledge, low vaccine confidence, and suboptimal uptake themselves."

In reflecting on the findings, the researchers note, for example, that: "The recognition that HCPs, a group often thought of as a trustworthy source, require reliable sources of their own heightens the importance of effective provider education to facilitate their influence on patient acceptance." They suggest that educational efforts aim to:

• Increase both HCPs' competency in vaccine education and their own vaccine acceptance;
• Provide updated disease and vaccine information from medical associations and government agencies to build HCPs' trust and guideline adherence;
• Segment clinicians by specialty or patient population to increase the relevance of vaccine information provided; and/or
• Instil the idea that vaccination is HCPs' responsibility.

In conclusion: "By expanding our knowledge about specific vaccine attitude–behavior associations and factors contributing to recommendation practice, this paper may guide the development of future interventions to increase HCP recommendation and their own vaccine uptake....Further examination of the roles of culture and social network in vaccination decision would better inform what interventions would prove most effective in specific communities...Moreover, comparing how vaccine misinformation and confidence have developed overtime could shed light on how health crises such as pandemics and changes in the healthcare system influence vaccine opinions and actions."