Vaccine hesitancy in health-care providers in Western countries: a narrative review

Figures & data

Figure 1. Steps for the selection of the articles.

Table 1. Description of the included articles (n = 39).

Reference number	First Author, Published Year	Country	Data Collection Period	Vaccines Considered	Population	Sample Size (Response Rate)	Data Collection Method	Information Collected
[28]	Verger, 2015	France	April-July 2014	MMR, HBV, MenC, HPV, influenza	GPs	1712 (46%)	Cross-sectional questionnaire	Demographics, patient recommendations, perceived likelihood of serious adverse events, perceived usefulness of vaccines, general opinions towards vaccination; perceived role in vaccination
[29]	Verger, 2016	France	April-July 2014	MMR, HBV, MenC, HPV, influenza	GPs	1712 (46%)	Cross-sectional questionnaire	Demographics, patient recommendations, perceived likelihood of serious adverse events, perceived usefulness of vaccines, general opinions towards vaccination; perceived role in vaccination
[30]	Thomire, 2021	France	October 2017-February 2018	Vaccination in general	Nurses	903 (9%)	Cross-sectional questionnaire	Demographics, vaccine confidence, convenience and complacency, CAM use, trust in health institutions, self-vaccination behaviors
[31]	Karlsson, 2019	Finland	February-March 2018	Childhood vaccinations (for HCPs with children) and influenza (self-vaccination)	GPs, nurses, head nurses & practical nurses in hospitals	4286 (49%)	Cross-sectional questionnaire	Beliefs about the benefits and safety of vaccines, general trust towards other health-care professionals, personal vaccination behavior, patient recommendation behavior in cases where patients are hesitant towards vaccines
[32]	La Torre, 2017	Italy	September 2014–August 2015	Influenza, tuberculosis, MMR, varicella, pertussis, HBV	Physicians, nurses, & biomedical students	571 (93.3%)	Cross-sectional questionnaire	Demographics, knowledge, attitudes and behaviors towards vaccine-preventable diseases, perceived risks
[33]	Rostkowska, 2021	34 EU countries	March-August 2016	Vaccination in general	Medical students & junior doctors	1,821 (NS)	Cross-sectional questionnaire	General attitudes towards vaccination and sources of information, knowledge and practices, attitudes towards mandatory vaccination, vaccine status
[34]	Killian, 2016	France	October 2013-January 2014	DTP, MMR, pneumonia, HBV, HPV, seasonal and H1N1 influenza and menC	GPs	693 (12.5%)	Cross-sectional questionnaire	Vaccination behaviors for themselves and their children, patient recommendations
[35]	Salek, 2020	Czech Republic	April 2019	Vaccination in general	Medical and teacher-education students	386 (NS)	Cross-sectional questionnaire	Lifestyle factors, vaccination, fear of side effects of vaccines or infectious diseases; attitudes towards alternative medicine
[36]	Eilers, 2015	The Netherlands	May-June 2013	Influenza, varicella, pertussis, pneumonia	GPs	10 (NS)	Semi-structured interviews	Perceived role concerning prevention in general, attitudes regarding current vaccination programs, vaccines, and reasons for vaccinating or not, practices and attitudes toward vaccinating elderly populations
[37]	Stefanoff, 2020	Poland	June-July 2017	Vaccination in general	Pediatricians and GPs	500 (19%)	Cross-sectional questionnaire	Support for vaccinations, vaccination practices for their children, vaccine status, vaccination myths
[38]	Di Martino, 2020	Italy	August-November 2019	Vaccination in general	Physicians, nurses, midwives	347 (NS)	Cross-sectional questionnaire	Attitudes and beliefs toward vaccination
[39]	Massot, 2018	France	September 2014-December 2017	Influenza and pertussis, vaccination in general	Midwives	917 (NS)	Cross-sectional questionnaire	Demographics, vaccine perception, vaccination status for mandatory and recommended vaccines
[40]	Vezzosi, 2019	Italy	October 2018	Influenza, pneumonia, varicella	GPs	73 (26.6%)	Cross-sectional questionnaire	Demographics, knowledge and attitudes toward specific vaccinations, vaccine status, experiences with patients
[41]	Tomljenovic, 2021	Croatia	July-December 2018	Vaccination in general and influenza, HPV, MMR	GPs, pediatricians, nurses	324 (65.5%)	Cross-sectional questionnaire	Vaccine safety, usefulness and necessity, perceived risks, attitudes towards mandatory vaccination, confidence in institutions and sources of information, perceived role in vaccination, knowledge
[42]	Collange, 2019	France	April-July 2014	MMR, MenC, HPV, HBV, influenza	GPs	2,586 (NS)	Cross-sectional questionnaire	Demographics, patient recommendations, vaccination coverage, confidence in authorities, safety and efficacy of vaccines
[43]	Neufeind, 2020	Germany	December 2017-January 2018	Influenza, pertussis, HBV	GPs	700 (NS)	Cross-sectional questionnaire	Vaccination status, patient recommendations, trust in institutions, sources of information, barriers to vaccination, vaccination promotion practices
[44]	Neufeind, 2021	Germany	January-March 2020	Vaccination in general and measles	Physicians	2,229 (NS)	Cross-sectional questionnaire	Demographics, attitudes toward mandatory vaccination, confidence in communicating with patients about vaccines, knowledge, patient position on vaccination
[45]	Tamburrano, 2019	Italy	2017–2018	Influenza, varicella, MMR, tuberculosis, DTP, HAV, HBV, MenC, pneumonia	Nurses and coordinating nurses	85 (NS)	Cross-sectional questionnaire	Beliefs about side effects, vaccine efficacy, patient recommendations
[46]	Elizondo-Alzola, 2021	Spain	March 2016-February 2017	Childhood vaccinations	Pediatric nurses	137 (83%)	Cross-sectional questionnaire	Demographics, perceived risks, beliefs on safety, social norms, knowledge about vaccines
[47]	Little, 2015	Great Britain	September 2013	MMR and influenza	Medical nurses, administrative staff, midwives	133 (NS)	Cross-sectional questionnaire	Demographics, vaccination history, knowledge of recommendations, reasons for lack of uptake, perceptions of vaccinations
[48]	Wilson, 2020	France	October 2017-March 2018	Mandatory and recommended vaccines for health-care workers^£	Nurses	1,539 (85%)	Cross-sectional questionnaire	Demographics, vaccination status, self-reported vaccine hesitancy, perceived risks of various vaccines, trust in sources of information on vaccination, confidence discussing risks and benefits of vaccines with their patients
[49]	Karnaki, 2019	14 EU countries	October 2012-April 2014	Influenza, tuberculosis, MMR, MenC, varicella, HAV, HBV, pneumonia, DTP	GPs and nurses	5,424 (NS)	Cross-sectional questionnaire	Demographics, specific vaccinations received over the last 10 years, reasons for not being immunized, attitudes and opinions toward obligatory vaccination
[50]	Raude, 2016	France	April-July 2014	Vaccinations in general and MMR, MenC, HPV, HBV, influenza	GPs	1,582 (92.4%)	Cross-sectional questionnaire	Demographics, frequency of recommendation, trust in sources of information, concerns about safety, beliefs about the importance/necessity of vaccines, confidence in their ability to explain the benefits and risks to patients, CAM practice, education related to vaccination
[51]	Lepiller, 2020	France	September 2018-May 2019	Vaccination in general	Medical students	530 (60.6%)	Cross-sectional questionnaire (before and after health promotion program)	Demographics, determinants of vaccine hesitancy, perceptions of vaccination, perceived preparedness to address vaccination concerns with patients
[52]	Karafillakis, 2016	4 European Union (EU) countries	NS	Vaccination in general	Physicians and nurses	65 (NS)	Semi-structured interviews	Vaccine hesitancy, perceptions of vaccine-related information, perceived role in responding to vaccine hesitancy
[53]	Harrison, 2016	Austria	March 2014	Recommended vaccines for health-care workers^§	Nurses	116 (58%)	Cross-sectional questionnaire	Demographics, vaccination status, reasons for and against vaccination, sources of information, knowledge, risk perception
[54]	Baldolli, 2020	France	March-April 2019	Mandatory and recommended vaccines*	Medical students	542 (11.9%)	Cross-sectional questionnaire	Demographics, vaccination coverage, vaccine hesitancy, benefit/risk balance, safety and efficacy of vaccines, opinions on recommended and mandatory vaccines in HCPs
[55]	Wilson, 2020	France	November 2016-April 2017	Vaccination in general	GPs	19 (NS)	Semi-structured interviews	Attitudes on benefits and risks of vaccines, patient recommendations, interactions with hesitant patients, trust in sources of information and authorities
[56]	Kunze, 2020	Austria	March 2015	HAV, HBV, MMR, varicella, pertussis, influenza	Medical students	1,184 (17.61%)	Cross-sectional questionnaire	Demographics, general opinions about vaccinations, attitudes toward mandatory vaccinations, vaccination status
[57]	Agrinier, 2017	France	December 2013- March 2014	HPV, MMR, HBV, MenC	GPs	1,712 (46%)	Cross-sectional questionnaire	Demographics, HCPs’ vaccination of their children, patient recommendations
[58]	Deml, 2019	Switzerland	August 2017- November 2018	Childhood vaccinations and HPV	CAM practitioners	17 (NS)	Semi-structured interviews and observations during consultations	Demographics, previous training/education, interactions during consultations, perspectives on vaccination and immunity, perspectives on medicine and public health
[59]	Dybsand, 2019	United States of America (USA)	March 2017	Vaccination in general	Medical, pharmacy & nursing students	223 (23.7%)	Cross-sectional questionnaire	Basic vaccine knowledge, vaccine hesitancy, patient recommendations, attitudes, confidence in addressing vaccination with patients, appraisal of the education received on vaccination
[60]	Manca, 2018	Canada	2013–2014 (and one interview in April 2015)	Measles, pertussis, influenza	Physicians and nurses	34 (NS)	Semi-structured interviews	HCPs’ narratives, experiences, and vaccine anxieties
[61]	Bonville, 2017	USA	NS	Childhood vaccines, HPV, influenza, DTP, varicella	Physicians	226 (41.5%)	Cross-sectional questionnaire	Vaccine beliefs, barriers, and immunization practices
[62]	Suryadevara, 2015	USA	June-November 2013	Childhood vaccinations, HPV, influenza	Pediatricians and nurses	680 (75.3%)	Cross-sectional questionnaire	Vaccine safety and effectiveness, patient recommendations, beliefs about side effects, self-reported vaccine hesitancy, sources of information, confidence in educating hesitant patients
[63]	MacDougall, 2015	Canada	NS	Influenza, pertussis, pneumonia, varicella	Nurses, GPs, pharmacists	1,167 (NS)	Cross-sectional questionnaire and focus group discussions	Attitudes towards vaccination recommendations, perceived role, benefits and risks of vaccination
[64]	Krishnaswamy, 2019	Australia	September-November 2016	Maternal vaccinations	GPs, midwives, obstetricians	870 (367/25% for obstetricians, 45/10% for obstetric trainees, 328/12% for GPs, 130/3% for midwives)	Cross-sectional questionnaire	Knowledge, perceived role in discussing and administering vaccines, current practices, and perceived barriers
[65]	Lee, 2018	New Zealand	2013–2014	Childhood vaccinations	GPs, pharmacists, midwives, dentists, CAM practitioners, & physiotherapists	1,032 (NS)	Cross-sectional questionnaire	Demographics, vaccine confidence
[66]	Eizayaga, 2015	Spanish & Portuguese-language countries	March-June 2015	Vaccination in general	CAM practitioners	512 (77.5% in Latin America, 16.8% in Spain)	Cross-sectional questionnaire	Vaccine hesitancy, attitudes towards vaccination (general beliefs on benefits, efficacy, safety; patient recommendations; opinions about mandatory vaccination)

MMR = measles, mumps, rubella; HBV = Hepatitis B Virus; MenC = meningitis C; HPV = Human Papillomavirus; GPs = General Practitioners; HCP = Health Care Professional; DTP = Diphtheria, Tetanus, Pertussis; HAV = Hepatitis A Virus, H1N1 = Hemagglutinin Type 1 and Neuraminidase Type 1 (also known as swine flu), NS = Not Specified

* Mandatory: DTP; Recommended: pertussis, HBV, measles, MMR, MenC, HPV, and varicella

^§DTP, polio, HAV, HBV, influenza, varicella, MMR & pneumococcal and meningococcal vaccines

^£Mandatory: BCG, DTP, HBV; Recommended: influenza, pertussis, varicella, and MMR

Table 2. Dimensions used to measure VH and reported prevalence.

Reference number	First Author, Published Year, Country	Dimensions used to measure VH	VH prevalence
[29]	Verger et al, 2016, France	Classification of vaccine-related attitudes and behaviors	11% moderately VH 3% highly VH
[41]	Tomljenovic et al, 2021, Croatia	25 questions to generate score between 25–125	17% (score ≤ 81)
[48]	Wilson et al, 2020, France	Responding “yes” to declining a vaccine considered dangerous or unnecessary, delaying a vaccine because of doubts, or accepting a vaccine despite doubts about its efficacy or safety	44% VH
[50]	Raude et al, 2016, France	Recommendation frequency, trust in sources of information, safety, necessity of vaccines (proxy for complacency), confidence in explaining benefits/risks (proxy for self-efficacy)	-
[51]	Lepiller et al, 2020, France	Contextual, individual and group influences	-
[54]	Baldolli et al, 2020, France	Score of 0–10 (0 = no hesitancy, 10 = maximal hesitancy)	20% (score ≥3)
[59]	Dybsand et al, 2019, USA	Safety, benefit/risk perception, efficacy, and recommendation for child vaccination	-
[61]	Bonville et al, 2017, USA	-	3%

Table 3. Proportions of HCPs vaccinated across studies.

Vaccine	Article [Ref]	Proportion covered (%)	Proportion by HCP group
Influenza	Karlsson, 2019 [31], Finland La Torre, 2017 [32], Italy Stefanoff, 2020 [37], Poland Di Martino, 2020 [38], Italy Massot, 2018 [39], France Tomljenovic, 2021 [41], Croatia Karnaki, 2019 [49], Europe^4 Wilson, 2020 [48], France	86.2^1 28.5 62^2 37.5^3 16.6^2 23.5^2 56.2^5 27^1	Physicians/GPs/Other^§ 94.7 – – 58.2 32.6 – 37.9^§	Nurses/Other* 69.4* – – 20.7/11.5* 16.3 – 22.6*
Diphtheritis-tetanus-pertussis (DTP)	Di Martino, 2020 [38], Italy Massot, 2018 [39], France Baldolli, 2020 [54], France Wilson, 2020 [48], France	42.7^3 89.3 93.5 57.5	36.1 – 95.4 52.5^§	30.7/38.5* – 94.2 59.3*
Hepatitis B	La Torre, 2017 [32], Italy Baldolli, 2020 [54], France Wilson, 2020 [48], France	82 88.2 61^6	– 96.5 49.1^§	– 95.3 65.8*
Varicella	La Torre, 2017 [32], Italy Wilson, 2020 [48], France	40 39	– 50.8^§	– 36.5*
Measles-mumps-rubella (MMR)	Di Martino, 2020 [38], Italy Baldolli, 2020 [54], France Wilson, 2020 [48], France	49.9^3 94.8 64	45.1 95.8 60.5^§	43.3/76.9* 94.2 64.6*

^§Other = Community nurses (Wilson, 2020).

*Other = Practical nurses (Karlsson, 2019), midwives (Di Martino, 2020), hospital nurses (Wilson, 2020).

¹Received influenza vaccine in the previous season.

²Reported taking influenza vaccine every year.

³Did not report missing vaccination.

⁴14 EU countries.

⁵Reported receiving at least one influenza vaccine in the last 10 years.

⁶At least three doses of the vaccine.

Table

Theme	Search string
Vaccine	*vaccination/ or *”mass vaccination”/ or *vaccines/ or *”immunization programs”/ or (immuni#ation* or immuni#e* or immuni#ing or vaccin*).ti,ab.
Knowledge, attitudes, behaviors	attitude/ or ‘attitude to health’/ or trust/ or uncertainty/ or *”Health Knowledge, Attitudes, Practice”/ or *”Attitude of Health Personnel”/ or (accept* or adherence or anxiet* or attitude* or barrier* or behavio?r* or belief* or choice* or compliance or confiden* or decision* or determinant* or dismiss* or factor* or hesita* or intention* or knowledge or mistrust* or motivat* or nonadherence or non-adherence or noncompliance or noncompliance or participat* or perception* or practice* or preference* or reason* or refus* or ‘risk perception’ or trust* willing*).ti,ab.
Health-care personnel	*”Health Personnel”/ or ‘Nurses’/ or ‘General Practitioners’/ or (‘HCP*’ or ‘HCW*’ or ((health or healthcare or nursing or medical or clinical or support or hospital or ‘health care’) adj1 (personnel or provider* or staff* or worker* or professional* or employee* or student*)) or ‘caregiver*’ or ‘nurse*’ or practitioner* or clinician* or specialist* or therapist* or doctor* or physician* or generalist* or ‘occupational health’ or pe?diatrician or pharmacist* or paramedic* or midwi#e* or gyne?cologist* or obstetrician* or chiropractici* or naturopath* or homeopath*).ti,ab,kf.

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