ABSTRACT
Community-wide vaccine uptake remains sub-optimal. Healthcare provider (HCP) vaccine recommendations influence patient vaccination; however, provider vaccine recommendation behavior is highly influenced by one’s own vaccine attitudes and/or knowledge. We aim to describe vaccine knowledge, attitudes, and recommendation practices (KAP) among New York State HCPs. A survey to assess HCP KAP was developed and electronically distributed to NYS members of national medical organizations via their local chapter administrators. Descriptive statistical methods were used to define provider KAP. A total of 864 surveys were included, 500 (60%) and 336 (40%) primary and specialty care providers, respectively. Eighty-one percent (402/499) of primary care providers (PCPs) report encountering vaccine hesitant patients daily or weekly. Of the 500 PCPs who responded, only 204 (41%) stated strong agreement with confidence in their communications with vaccine hesitant patients. HCPs who correctly answered all four knowledge questions were more likely to self-report routine recommendations of standard vaccines to all patients when compared to those who correctly answered fewer questions (489/588 (83%) vs 135/241 (56%), p < .05). HCPs were more likely to routinely recommend standard vaccines to all patients if they also report initiating vaccine discussion (476/485 (98%) vs 148/344 (43%), p < .05) and reviewing and recommending vaccinations at each encounter (315/320 (98%) vs 308/508 (61%), p < .05). Vaccine hesitancy exists across healthcare specialties and provider roles. Focused interventions should include reaching all HCPs to promote vaccinations for disease prevention, tailoring messages to reduce HCP vaccine misperceptions, and increasing awareness of evidence-based office strategies known to facilitate immunizations.
Introduction
Vaccines are commonly regarded as one of the greatest innovations in medical history, having dramatically reduced morbidity and mortality from life-threatening diseases. Yet, there continues to be pockets of under- and un-immunized individuals. While low vaccination rates in the adult population are not new, there has been a dramatic decline in pediatric and adolescent vaccine uptake since the start of the SARS-CoV-2 pandemic.Citation1,Citation2 Urgent intervention is needed to reverse this trend, particularly in the adolescent and adult population, in order to protect the community from vaccine-preventable disease outbreaks.
Factors influencing vaccine uptake have been identified throughout the healthcare delivery system, at the patient, provider, and practice levels. For example, logistical barriers, such as disruption in vaccine administrations due to stay-at-home orders and regional lockdowns during the SARS-CoV-2 pandemic, likely played some role in the current low vaccine coverage rates.Citation3 In addition, patient and provider vaccine attitudes impact vaccine acceptance, with the strongest factor associated with patient vaccine acceptance being the receipt of vaccine recommendation by their healthcare provider.Citation4 Yet, despite vaccine guidance provided by national organizations, healthcare provider recommendation practices are still highly influenced by one’s own vaccine attitudes and knowledge.Citation4–6 Specifically, providers with positive attitudes regarding vaccine safety, efficacy, and benefits are more likely to deliver strong vaccine recommendations.Citation6
More recently, healthcare provider vaccine hesitancy has been identified as a barrier to optimizing vaccine uptake.Citation4,Citation6,Citation7 Vaccine hesitancy, defined as the delay in acceptance or the refusal of vaccination despite the availability of vaccination services, has been listed by the World Health Organization as a top ten global threat to public health.Citation8,Citation9 Identifying provider vaccine hesitancy and understanding how these attitudes relate to vaccine behaviors and practices can guide efforts to improve community-wide vaccine uptake. The primary objective of this study is to describe vaccine knowledge, attitudes, and recommendation practices among primary and subspecialty care physicians and mid-level providers across New York State. The secondary objective is to identify factors associated with vaccine knowledge, attitudes, and recommendation practices, including perceived barriers to vaccination and vaccine hesitancy in the practice.
Methods
For this prospective descriptive study, the study team developed an anonymous self-administered questionnaire regarding healthcare provider’s vaccine knowledge, attitudes, and recommendation practices. The survey was pilot tested with a convenience sample to ensure clarity of questions and ease of administration. In an effort to increase the opportunity for survey completion, the questionnaire was electronically and directly distributed by the NYS chapters of the American Academy of Pediatrics, Academy of Family Physicians, Medical Society of the State of New York, and the Nurse Practitioners Association to their organization members at four separate times between September 15, 2021, and January 1, 2022. All members of these medical organizations were eligible for inclusion, and there were no exclusion criteria for study participation. The study was determined to be exempt for review by the SUNY Upstate Medical University Institutional review board (IRB 1797883).
Demographic information, including gender, race, ethnicity, county of practice, field of practice, healthcare provider role, and community served was collected. Additionally, information regarding various aspects of vaccine administration in the office was also obtained. Healthcare provider vaccine knowledge assessment comprised four statements for which the participants responded with “True,” “False,” or “I don’t know.” The questions were given a score, with 1 point added for each correct answer. The denominators presented in the results section represent the number of providers who answered the question(s) described. A cut-off of 75% (answering 3 of the 4 questions correctly) was considered a “good” level of vaccine knowledge. Assessment of provider vaccine attitudes regarding vaccine importance, safety, and efficacy comprised 10 items using an ordinal scale questionnaire (strongly disagree, disagree, neutral, agree, strongly agree). For the statement, “influenza infection is not serious enough to warrant annual vaccination,” 1 point was given for strongly agree, 2 points for agree, 3 for neutral, 4 for disagree, and 5 for strongly disagree. For each of the other statements assessing provider vaccine attitudes, 1 point was given for strongly disagree, 2 points for disagree, 3 for neutral, 4 for agree, and 5 for strongly agree. Higher scores reflect more favorable attitudes. A cut-off of 75% (scoring above 37.5 out of 50) was considered to represent “positive” vaccine attitudes. Healthcare provider vaccine practices were assessed by six questions regarding routine recommendations of all standard vaccines, with specific questions about the influenza and tetanus-diphtheria-acellular pertussis vaccines (). Questions regarding recommending vaccines for pregnant women were excluded from the scoring as this reflects a sub-population of the study participants. For the other four questions, which were included in the scoring, 1 point was given for an answer of Never, 2 points for Sometimes, 3 for Often, and 4 for Always. Higher scores reflect favorable vaccine recommendation practices. A 75% cut off (scoring above 12 out of 16) was considered to represent “favorable” vaccine recommendation practices. The end of the study addressed questions regarding vaccine hesitancy among the participant, the participant’s practice staff and patients. Open-ended questions were used to elicit both barriers to vaccination in the practice, as well as provider vaccine safety or efficacy concerns.
Table 1. Questions assessing vaccine knowledge, attitudes, and recommendation practices among healthcare providers in New York State.
Study data was collected and managed using REDCap electronic data capture tools hosted at SUNY Upstate Medical University.Citation10,Citation11 REDCap (Research Electronic Data Capture) is a secure, web-based software platform designed to support data capture for research studies, providing 1) an intuitive interface for validated data capture; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for data integration and interoperability with external sources.
Statistical analysis
Categorial and Likert scale variables were summarized by frequencies and proportions, for all responders and responders from physicians and mid-level providers, respectively. To test the difference between physicians and mid-level providers, Pearson’s chi-square tests and two-sample t-tests were used for comparing categorical variables and Likert scale variables, respectively. Mean plots and bar charts were used to visually present the data.
Results
Healthcare provider demographics
Eight hundred and sixty-four surveys were received (for a response rate of 6.2%), including 672 (78%) physicians and 192 (22%) mid-level practitioners (). In total, 500 (60%) and 336 (40%) reported practicing primary and subspecialty care, respectively, with no statistical difference between physicians and mid-level providers. One-quarter of the responding providers have been in practice for 10 y or less, almost half of the providers have been in practice for 11 to 30 y, and just under a third of providers have been in practice for over 30 y. The majority of responding providers care for patients in suburban (451, 52%) and urban (384, 44%) communities.
Table 2. Demographic characteristics of participating New York State healthcare providers.
Of the total providers who responded, 385/864 (45%) reported administering vaccines in their practice, with mid-level providers (136/192, 71%) more likely to report this than physicians (249/672, 37%) (p < .05). Physicians were more likely than mid-level providers to state a preference that patients receive their influenza vaccines (127/666 (19%) vs 24/192 (3%)), and other (non-influenza, non-COVID-19) vaccines (314/672 (47%) vs 56/191 (29%)) in the medical office ().
Table 3. Vaccine administration characteristics among participating New York State healthcare providers.
When stratified by healthcare field of practice, primary care providers (452/500, 90%) were more likely to report administering vaccines in the practice than specialty care providers (100/336, 30%) (p < .05). However, while most of the primary care providers reported administering vaccines in the practice, only 282 (56%) stated that they could access practice vaccination rates. The majority of primary care providers reported no preference between medical office or pharmacy as a site for vaccinations for the influenza vaccine (383, 56%) and the COVID-19 vaccine (393, 79%). Primary care providers (274/500, 55%) were more likely to prefer the medical office as the site of vaccination for non-influenza, non-COVID-19 vaccines than specialty care providers (87/335, 30%) (p < .05).
Vaccine communication and role attitudes
Of the 863 providers who answered the question, only 705 (82%) stated agreement or strong agreement with the statement, I am confident in my ability to communicate with vaccine hesitant patients and families. Regarding vaccination roles, mid-level providers were more likely than physicians to agree or strongly agree with the following statements: recommending and/or administering vaccines is within my scope of practice (177/191 (93%) vs 524/664 (79%), p < .05) and other providers recognize my role in vaccinating patients (129/191 (68%) vs 378/672 (56%), p < .05) ().
Figure 1. Percentage of responses regarding vaccination roles (a) and vaccine attitudes (b) stratified by participating NYS physicians and mid-level providers. *represents a p < .05 when comparing physicians’ responses and mid-level providers’ responses.
Of the 500 primary care providers who responded, less than half (204, 41%) stated strong agreement with the statement, I am confident in my ability to communicate with vaccine hesitant patients and families. Primary care providers were more likely than specialty care providers to agree or strongly agree with the statements: I am confident in my ability to communicate with vaccine hesitant patients and families (440/500 (88%) vs 245/335 (73%), p < .05), recommending and/or administering vaccines is within my scope of practice (483/499 (97%) vs 199/334 (60%), p < .05), it is my responsibility to ensure that my patients are fully vaccinated (468/500 (94%) vs 180/335 (54%) p < .05), and that other providers recognize my role in vaccinating patients (404/500 (81%) vs 85/335 (25%), p < .05).
Vaccine attitudes
Overall, healthcare providers reported positive vaccine attitudes, with 89% (770/863) of providers responding with favorable scores over 37.5/50 (). In total, only 797/862 (92%) of providers stated agreement or strong agreement with the statement, vaccines for diseases uncommon in the US are still important. With regard to influenza vaccine, 95% (820/863) disagreed or strongly disagreed with the statement, influenza infection is not serious enough to warrant annual vaccination and 93% (799/863) agreed or strongly agreed with the statement, influenza vaccine is effective in preventing severe influenza. Similarly, 95% (814/861) and 97% (836/861) of providers stated agreement that COVID-19 vaccines were safe and effective, respectively. Physicians were more likely than mid-level providers to agree or strongly agree that the benefits of vaccines outweigh the risks (662/672 (99%) vs 180/191 (94%), p < .05) and to strongly agree that the COVID-19 vaccine is safe (557/671 (83%) vs 123/190 (65%), p < .05) and effective (583/672 (87%) vs 143/190 (75%), p < .05) (). Providers who agreed or strongly agreed that the influenza vaccine is effective in preventing severe disease were more likely to also agree that the COVID-19 vaccine is effective in severe disease prevention (798/782 (98%) vs 54/64 (84%) p < .05). Primary care providers were more likely than specialty care providers to disagree or strongly disagree with the statement that influenza is not serious enough to warrant annual vaccination (482/500 (96%) vs 313/335 (93%), p < .05) and to agree or strongly agree that the influenza vaccine is effective in preventing severe influenza (480/500 (96%) vs 294/335 (88%), p < .05). There were no other statistical differences between primary care and specialty care providers regarding vaccine attitudes.
Table 4. Aggregate healthcare provider responses to questions assessing vaccine knowledge, attitudes, and recommendation practices.
Vaccine knowledge
Overall, healthcare providers had a “good” level of vaccine knowledge, with 91% (783/864) correctly answering at least 3 of the 4 questions (). While almost all providers (642/648, 99%) correctly responded that there is no clear link between vaccinations and autism, 18% (145/825) of providers did not know that vaccines should not be deferred for mild illness. Physicians were more likely than mid-level providers to correctly report that multiple vaccines do not overwhelm the immune system (639/652 (98%) vs 157/173 (91%), p < .05) (). Primary care providers were more likely than specialty care providers to correctly report that there is no clear link between vaccinations and autism (480/500, 96% vs 307/335, 92%, p < .05), multiple vaccines administered at the same visit do not overwhelm the immune system (470/500, 94% vs 301/335, 90%, p < .05), vaccines do not need to be deferred for mild illness (438/500, 88% vs 223/335, 67%, p < .05), and provider vaccine recommendation is associated with vaccine acceptance (471/500, 94% vs 299/335, 89%, p < .05).
Figure 2. Vaccine knowledge (a) and practices (b) among NYS healthcare providers stratified by physicians (P) and mid-level providers (ML). *represents a p < .05 when comparing physicians’ responses and mid-level providers’ responses.
Vaccine recommendation practices
Overall, less than ¾ of healthcare providers (589/864, 68%) responses reflected favorable vaccine recommendation practices, with scores over 12/16 (75%) (). When including all providers who answered the question, 86% (624/725) reported always routinely recommending standard vaccines to all patients. Of these 624 providers, only 527 (84%) self-report routinely recommending the influenza vaccine to their patients. Similarly, of the providers who report always recommending standard vaccines to their patients, only 256/471 (54%) and 230/468 (49%) always recommend the influenza and Tdap vaccines, respectively, to pregnant women.
Of the 863 providers who answered the question, 23 (3%) do not get the annual influenza vaccine, stating concerns for side effects (4, 17%), low vaccine efficacy (3, 13%), low perceived disease risk (2, 9%), low priority (2, 9%), not necessary (2, 9%), and medical precaution or caution (2, 9%). Providers who receive an annual influenza vaccine are more likely than those who do not to routinely recommend influenza vaccine to all patients (555/799, 69% vs 6/22, 27%, p < .05) and to routinely recommend the influenza vaccine to all pregnant women (287/388, 74% vs 2/12, 17%, p < .05). Four providers have not yet and do not intend to receive the COVID-19 vaccine stating concerns for safety, efficacy, and coercion. Only one of these four receive the annual influenza vaccination.
502/758 (66%) of providers always initiate the vaccine discussion with patients, and less than half (320/662 (48%)) of providers always review and recommend vaccines at each visit. Physicians (484/547, 88%) were more likely than midlevel practitioners (140/177, 79%) to routinely recommend all vaccines to all patients (p < .05). There were no other statistical associations between provider level and vaccine practices ().
Primary care providers who administer vaccines in the practice are more likely than those who do not to always routinely recommend standard vaccines to all patients (406/434 (94%) vs 25/38 (67%), p < .05). Only 396/500 (79%) primary care providers report always initiating the vaccine discussion with patients, with 263/472 (56%) reviewing and recommending immunizations at each medical visit. Among primary care providers who answered the question 431/472 (91%) reported always routinely recommending standard vaccines to all patients. However, of these providers who answered the question, only 393/431 (91%) self-report routinely recommending the influenza vaccine to their patients, 198/293 (68%) and 186/293 (63%) routinely recommending the influenza and Tdap vaccine, respectively, to pregnant women.
Positive vaccine attitudes were statistically associated with reporting routine recommendations of standard vaccines to all eligible patients (). Healthcare providers who correctly answered all four of the vaccine knowledge questions were more likely to self-report routine recommendations of standard vaccines to all eligible patients when compared to those who correctly answered fewer questions (489/588 (83%) vs 135/241 (56%), p < .05). In addition, healthcare providers were more likely to routinely recommend standard vaccines to all eligible patients if they also report initiating the vaccine discussion with their patients (476/485 (98%) vs 148/344 (43%), p < .05) and reviewing and recommending vaccinations at each patient encounter (315/320 (98%) vs 308/508 (61%), p < .05).
Figure 3. Association of vaccine attitudes and vaccine practices among NYS healthcare providers. *represents a p < .05 when comparing responses among those who strongly agreed with the statement and those who did not strongly agree.
There was no association between preference for influenza vaccination site and one’s self-report of routine recommendation of influenza vaccine to all eligible patients (including pregnant women). Routine recommendation of influenza vaccine to all eligible patients is associated with strong disagreement with the statement, influenza infection is not serious enough to warrant annual vaccination (366/487 (75%) vs 195/347 (56%), p < .05) and strong agreement with the statement influenza vaccine is effective in preventing severe (353/461 (77%) vs 208/373 (56%), p < .05). In addition, providers who expressed strong agreement with the statement, I am confident in my abilities to communicate with vaccine hesitant families were more likely to routinely recommend influenza vaccine to all eligible patients compared to providers who did not express strong agreement (252/313 (81%) vs 308/520 (60%), p < .05).
Barriers to vaccination
Eleven percent (90/857) of providers stated strong agreement or agreement with the statement that vaccine access is a barrier to vaccination in the practice. Mid-level practitioners were more likely than physicians to agree or strongly agree with this statement (31/191 (16%) vs 59/666 (9%), p < .05).
Almost one-quarter (201/858, 23%) of surveyed providers stated that lack of staffing was a barrier to vaccination in the practice. Over 10% of providers stated that reimbursement, insurance coverage, recordkeeping, and compensation, each, were barriers to vaccination in the practice. In addition, other barriers noted include patient factors (parent or patient hesitancy, mistrust of the medical and public health systems, the spread of vaccine mis-information), practice factors (provider and/or office staff vaccine hesitancy, limited office space for vaccine appointments and/or vaccine storage, not enough time with patients for vaccine counseling, limited appointments available for vaccine administration), and factors related to vaccine logistics (vaccine storage and handling requirements, multi-dose vials lead to wasted vaccines, difficulty in separating vaccines for publicly and privately insured patients, difficulty with Vaccines For Children’s program logistics, access, shipping delays, and regulations, inability to receive vaccines in a timely manner, and cost of maintaining inventory).
Vaccine confidence and hesitancy
In total, 107/862 (12%) and 152/860 (18%) of providers expressed concern with the safety and efficacy, respectively, of at least one vaccine. There was no statistical difference between the provider role and vaccine efficacy concerns. Mid-level practitioners were more likely to express vaccine safety concerns than physicians (32/190, 17% vs 75/672, 11%, p < .05). There were no statistical differences in vaccine safety or efficacy concerns between primary care and specialty care providers. Of the 94 responses, the most common vaccine listed with regard to provider vaccine safety concerns was the COVID-19 vaccine (78 (83%)), followed by all vaccines (7 (7%), influenza vaccine (3 (3%)), and HPV vaccine (3 (3%)). Of the 140 responses, the most common vaccines listed with regard to provider vaccine efficacy concerns were the COVID-19 vaccine (76 (54%)), followed by influenza vaccine (56 (40%)), pneumococcal vaccine (5 (4%)), meningococcal B vaccine (4 (3%)), and all vaccines (3 (2%)). Providers reported confidence in vaccine information guidance received from the Centers for Disease Control (708/864, 82%), one’s medical organization (528/687, 77%), and the New York State Department of Health (637/864, 74%).
A total of 360/863 (42%) of providers stated that they believed there were vaccine hesitant staff in the practice. An additional 127 (15%) did not know if any of their staff was vaccine hesitant. Vaccine hesitant individuals were identified in each role of the office, from front office staff to the practicing providers. About 98% of all surveyed providers encounter vaccine hesitant patients at least monthly, with 335 (39%) providers reporting vaccine hesitant encounters as frequently as daily and weekly. Up to 81% (402/499) of primary care providers report encountering vaccine hesitant patients daily or weekly.
Discussion
In this work, we describe vaccine knowledge, attitudes, and recommendation practices among New York State healthcare providers. Overall, we found that healthcare providers in New York State had good level of vaccine knowledge and positive vaccine attitudes. However, we did identify areas of vaccine hesitancy, in the forms of vaccine misperceptions, vaccine concerns, and limited delivery of routine vaccine recommendations, to be present across provider specialties. In addition, we found that positive vaccine attitudes and high vaccine knowledge scores each were positively associated with routine delivery of vaccine recommendations. Understanding differences in vaccine knowledge and attitudes by provider roles and specialties can guide targeted interventions to promote vaccine confidence, thereby increasing provider vaccine recommendation practices and ultimately patient vaccine acceptance.
We found that primary care providers and physicians (compared to mid-level providers) preferred that their patients receive their non-influenza, non-COVID-19 vaccines in the medical office, yet 8% of our surveyed primary care providers do not administer vaccines in the practice. Recommending but not administering vaccines in the practice reduces ease of access to vaccinations among patients in the office and may contribute to reduced vaccine uptake.Citation12 Yet, it is important to note that the overall proportions of vaccinations being given in community pharmacies are on the rise, with increased convenience, patient satisfaction, and reduced healthcare costs associated with utilization of these services.Citation13–15 Pharmacy-located vaccine clinics also help to reduce barriers to vaccinations identified in this work, including lack of staffing in the medical office and limited appointments available for vaccine administrations. Collaborations between community pharmacists and healthcare providers, particularly those who do not administer vaccines in the office, should be encouraged to optimize vaccine administration opportunities in locations where patients are already accessing other services.
Almost one-tenth of the primary care providers who state that they always recommend standard vaccines to all eligible patients go on to endorse that they do not routinely recommend the influenza vaccine to all patients. Similarly, one-third of these providers report not routinely recommending the influenza vaccine to all eligible pregnant women. These data suggest that, despite organizational guidelines for routine administration of the annual seasonal influenza vaccine to all eligible patients, healthcare providers do not consider this to be a part of the standard vaccine series. Consistent with prior research,Citation4–18 we found that routine recommendation of influenza vaccine to all eligible patients was associated with provider’s self-receipt of the annual seasonal influenza vaccine, the understanding that influenza infection is severe enough to warrant vaccination, and that the vaccine is effective in preventing severe disease. When studied globally, the most consistent determinant of provider influenza vaccine recommendation was found to be the provider’s own influenza vaccine receipt.Citation19 However, influenza vaccine uptake among healthcare workers is inconsistent, with higher rates noted among individuals with employer-required vaccination policies.Citation20,Citation21 Similar to what we found in our study, low perception of disease risk and limited knowledge regarding the safety and efficacy of influenza vaccine were common reasons cited for declining the influenza vaccine.Citation22 The impact of a healthcare provider’s recommendation on seasonal influenza vaccine uptake has been well described.Citation23,Citation24 Future efforts, therefore, should focus on increasing healthcare provider awareness regarding influenza infection severity, influenza vaccine safety and efficacy, and the ACIP recommendation that all eligible patients receive a seasonal influenza infection annually. This will help to increase both healthcare provider receipt of the influenza vaccine and the likelihood of delivering appropriate vaccine recommendations to their patients.
Less than half of primary care providers strongly agreed with being confident in their ability to communicate with vaccine hesitant patients and families, despite the majority of these providers encountering vaccine hesitancy either daily or weekly. Vaccine communication between the healthcare provider and the patient and/or family is a crucial component of the medical visit. While provider vaccine recommendation is a key factor associated with patient vaccine uptake, the communication of the vaccine message, including the timing of the conversation, the strength of the recommendation, and the confidence of the person delivering the message, influences vaccine decision-making.Citation25 Providers who can effectively communicate the benefits and risks of vaccination and the importance and safety of vaccines have the potential to increase patient and parental confidence in vaccination.Citation26 On the other hand, poor communication by the provider can negatively impact the patient’s or family’s decision to vaccinate.Citation27 Vaccine communication strategies that have been shown to improve vaccine uptake include addressing vaccine myths and misinformation in a manner that keeps the patients and/or parents engaged in the conversation, delivering a strong presumptive vaccine recommendation, using motivational interviewing techniques, and tailoring the vaccine message to each individual patient.Citation28 In fact, the use of the presumptive vaccine recommendation has been associated with not only with increased vaccine uptake but also efficiency of the vaccine discussion.Citation29 This is especially important for providers in this study who listed a lack of time for vaccine counseling or vaccine discussion as a barrier for vaccination. Combining scientific information with personal anecdotes may be needed in vaccine discussions with some patients and/or parents; however, providers need to be confident in their vaccine knowledge for this to be effective.Citation25 We found persistence of vaccine misperceptions among some surveyed healthcare providers, which may negatively impact vaccine confidence and subsequently vaccine communications with their patients and families. Therefore, important priorities highlighted by the findings of our study include delivering education regarding vaccine communication strategies as well as improving awareness of vaccine importance in disease prevention and dispelling common vaccine myths that continue to cause confusion and uncertainty about vaccines. Addressing these priorities will increase healthcare provider vaccine confidence and improve their vaccine communication effectiveness and efficiency with their vaccine hesitant patients and families.
Over 40% of surveyed providers reported vaccine hesitancy among at least one office staff member, with roles ranging from front office staff to other providers in the practice. Vaccine hesitancy in the medical practice, even among non-clinical staff, negatively impacts patient vaccine uptake.Citation30,Citation31 Office-based strategies to improve vaccine uptake within the practice include developing a culture of immunization, where all staff members are engaged in and in support of the promoting and facilitating vaccinations for disease preventions.Citation25 Along these lines, the Centers for Disease Control and Prevention (CDC) have developed educational materials to train clinical providers and staff on vaccine safety and importance in an effort to promote vaccine confidence across the healthcare team.Citation25 In addition, the CDC suggests that healthcare providers should review immunization status and recommend vaccines that are due at each clinical visit.Citation1 However, we found that despite this guidance, only half of the surveyed primary care providers review immunization status and recommended vaccines that are due at each clinical visit. Immunizing patients at each clinical visit reduces missed opportunities for vaccination, particularly among patients who do not routinely attend well medical visits.Citation13 These data suggest that even though 80% of surveyed providers reported confidence in vaccine information by the CDC, this guidance alone is not sufficient to change vaccine-related behaviors. Interventions to bring this information to healthcare providers are needed to improve awareness of these evidence-based strategies and to identify and overcome barriers to these practices.
Not surprisingly, primary care providers, when compared to specialty care providers, were more likely to administer vaccines in their practice, have higher vaccine knowledge scores, and increased confidence in vaccine communications, and have higher mean levels of agreement that they felt responsible in ensuring that patients were fully vaccinated and that promoting vaccines was within their scope of practice, and feeling responsible to ensure that patients are fully vaccinated. With declining vaccination rates across the countries, all healthcare providers, including those in primary and specialty care fields, have the opportunity to educate patients on the importance of vaccines for disease prevention. The ACIP has provided written support of these discussions by subspecialty care providers to reduce missed opportunities for vaccinations, particularly for patients with underlying medical conditions placing them at high risk for vaccine-preventable disease.Citation32 With over three-quarters of surveyed healthcare providers expressing confidence in vaccine information from their own medical organizations, the delivery-specific vaccine guidance to specialty care providers, designed to improve vaccine confidence and reinforce their role in promoting vaccines for disease prevention, may influence and facilitate vaccine discussions in these healthcare settings.
Ten to twenty percent of surveyed providers expressed concerns with the safety or efficacy of at least one vaccine, most commonly the COVID-19 vaccine, with no difference by provider role or field of healthcare practice. Similar to what was described by Paris et al.,Citation33 we found that providers with confidence in influenza vaccine effectiveness in severe disease prevention were more likely to also express confidence in COVID-19 vaccine efficacy. Global reviews found that COVID-19 vaccine hesitancy among healthcare workers ranged from 4% to 72%, with concerns of vaccine safety, efficacy, and potential side effects as the main factors associated with hesitancy.Citation33–35 With persistent circulation and availability of booster vaccines, further understanding of healthcare attitudes regarding COVID-19 vaccines is needed to guide interventions focused on reducing hesitancy.
There are several limitations associated with survey studies, including recall bias with regard to questions about vaccine practices as well as low response rate and selection bias, which is a result of voluntary study participation that may inadvertently lead to potential selection bias of vaccine confident providers. However, despite these limitations, it is important to assess vaccine knowledge, attitudes, and self-reported practices among healthcare providers in order to identify areas to target when developing interventions to improve vaccine confidence and vaccine uptake.
Conclusion
Vaccine knowledge and attitudes of healthcare providers significantly influence vaccine recommendation practices, yet we found vaccine hesitancy to exist among healthcare providers across specialties and provider role. Specifically, specialty care providers are a point of contact with patients who are potentially unimmunized. However, as a group, these providers may not feel that promoting vaccines is not within their scope of practice, leading to avoidance of the vaccine discussion altogether. Despite clear organizational guidance, healthcare providers are still not routinely recommending standard vaccines to all eligible patients or reviewing and recommending immunizations at each clinical visit. With an ultimate goal of improving patient vaccine coverage rates, interventions should include reaching all healthcare providers to promote vaccinations as disease prevention, tailoring messages to reduce healthcare provider vaccine misperceptions, and increasing awareness and feasibility of evidence-based office strategies known to facilitate immunizations among their patients.
Author contribution
AF contributed to study implementation, data collection and analysis, drafting the manuscript, and critical review of the manuscript. MS contributed to study design and implementation, data collection and analysis, drafting the manuscript, and critical review of the manuscript. DW contributed to study design, data collection and analysis, and critical review of the manuscript. JD contributed to study design, data collection and analysis, and critical review of the manuscript.
Disclosure statement
No potential conflict of interest was reported by the authors.
Additional information
Funding
References
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