Survey of Healthcare Providers' Views and Experiences with Vaccine Hesitancy

This survey of 2,004 family physicians, nurses, pharmacists, midwives, and specialists was conducted for the Public Health Agency of Canada (PHAC) by Environics Research in order to provide the agency with a clearer picture of exactly how widespread concerns about vaccines have become in Canada. PHAC identified the need for public opinion research to understand healthcare providers' (HCPs') perspectives of, and experiences with, vaccine delay/refusal at a time when the number of Canadians who are delaying /refusing immunisation is increasing. The research was needed to understand how HCPs communicate with patients about vaccination, how the rate of hesitancy is changing over time, and what tools and resources HCPs are aware of/utilise to find information on vaccines and messages/strategies to encourage hesitant patients to accept vaccines.

The survey was carried out in the context of repeated outbreaks in recent years of preventable illnesses, including measles, mumps, and whooping cough across, Canada and Europe. Data from the federal government suggests there has been a 30% spike in recent years in cases of infectious diseases that could be prevented by people getting their vaccinations: 6,184 cases were reported in 2005, while 8,018 were reported in 2014. Herd immunity to such illnesses is generally achieved when 95% of the population is vaccinated against them. Rates of vaccinations are declining, however, with about 90% of Canadians actually protected. That number ranges depending on the vaccine in question: for example, 91% of Canadian children are vaccinated against polio by the age of 2, while just 77% are vaccinated against diptheria, pertussis, and tetanus (DPT) by the same age. The vaccination rate at the same age for measles, mumps and rubella (MMR) is 79%.

To address the research objectives, an online survey was conducted between November 21 2017 and January 25 2018 with 5 separate groups of HCPs who provide vaccines or advice on vaccines: general practitioners, family doctors (n=535); midwives (n=297); nurses (n=493); pharmacists (n=601); and specialists (obstetricians/gynaecologists and paediatricians) (n=78).

The following presents the key findings of the research, first in terms of the overall themes. In sum:

HCPs' experience with patient vaccine hesitancy:

• HCPs appear to be encountering vaccine hesitancy in their practices on a regular basis. The consensus is that patients express reluctance "some of the time", with a small proportion of HCP respondents who say that it happens more often than that. HCP experiences with outright refusals or requests for alternative schedules are much rarer.
• HCP respondents are widely concerned about patient vaccine reluctance, with at least 8 in 10 or more saying that it is at least somewhat of an issue facing public health. Between 36% and 38%, not including specialists, said it was "a significant issue". Among specialists, 53% said the same.
• There are mixed views about whether there has been a shift in the frequency of vaccine reluctance, refusals, alternative schedule requests, and patients mentioning incorrect vaccine information over the past 5 years, but the largest proportion within each HCP type (roughly 50% or more) have not perceived any change. The exception is specialists, who are most likely to feel these occurrences have increased. Similarly, HCP respondents generally believe that patient expressions of support for vaccination and their knowledge of the topic have remained the same compared to 5 years ago.
• In the past year, HCPs heard a wide variety of reasons from patients as to why they did not want themselves or their family members vaccinated. The main reasons revolve around vaccine safety, including concerns about specific vaccine ingredients, concerns about possible long-term effects, and knowing someone who had an adverse reaction to a vaccine. "Significant proportions of each HCP type have also heard reasons related to under-estimating the threat of disease, lack of trust in institutions, and belief in alternative therapies", the authors stated. Of those who said patients expressed a lack of trust in institutions, between 50% and 64% of HCPs surveyed said that this came in the form of conspiracy theories about pharmaceutical companies and the government. HCP respondents most often encountered patient reluctance around the MMR/MMVR (MMR plus varicella), varicella, human papillomaviruses (HPV), rotavirus and herpes zoster vaccines.

HCPs' knowledge/attitudes/beliefs about vaccine effectiveness and safety:

• There is a broad and strong consensus among HCPs that vaccines in use in Canada are safe and effective, that they trust the recommendations of the National Advisory Committee on Immunization (NACI), and that the vaccine regulatory system in Canada is working effectively. Most respondents also strongly disagree with negatively-worded statements about vaccines, including concerns that the HPV vaccine could lead to unprotected sex and about the lower effectiveness and safety of administering multiple vaccines at a single visit.
• Just over one in 10 family physicians, nurses, pharmacist, and specialists say there is at least one vaccine they are reluctant to recommend. Reported vaccine reluctance is higher among midwives (34%).
• Each HCP type describes themselves as most comfortable understanding and applying vaccine recommendations among the patient groups with which they have the most experience; this means that family physicians and nurses are more comfortable with a broader range of patients than are specialists, pharmacists, and midwives. All HCP types are least comfortable with vaccine recommendations for immunocompromised patients.

Preparedness for patient communications:

• In general, HCP respondents consider themselves at least somewhat prepared to personally address patients' vaccine concerns, although only a minority feel very prepared.
• The messages that HCPs feel have been most effective in helping vaccine-hesitant patients become more comfortable with vaccinations fall into 3 broad themes: providing information, research and, evidence; reinforcing the effectiveness of the vaccines (e.g., disease prevention and other benefits); and addressing safety concerns. Relatively few say they have effectively used messages focused on dispelling existing myths.
• HCP respondents' degree of comfort providing vaccine advice to patients where language barriers exist is mixed: Half or fewer describe themselves as at least somewhat comfortable in this role. There does appear to be a gap in vaccine resources for patients who do not speak Canada's official languages. While most HCPs except for midwives believe they have adequate access to information resources that help them address patient concerns about vaccination, only a minority of each HCP type say they have adequate access to resources to support patients who speak a language other than English or French.

Information sources:

• Of the options presented, the Canadian Immunization Guide (CIG) is universally preferred by all HCP types for updating their own vaccine knowledge, followed closely by statements from NACI (provincial/territorial protocols and guidance documents were not provided as an option). Medical journals, conferences, and professional association newsletters are also commonly used, but the extent varies by HCP group. There is room to grow the use of CIG's email updates, which are currently used by only a small subset of HCP respondents. The main barrier is a lack of awareness of this subscription service.
• Aside from the CIG, the next most widely known and used PHAC product is 'A Parent's Guide to Vaccination' among nurses and midwives specifically. Frequency of use of other PHAC resources is low.
• HCPs typically display printed health promotional materials in waiting and exam rooms, while nurses and midwives are among the most likely to give them directly to patients. When it comes to vaccine information specifically, printed resources are more widely used than digital ones, although the former tend to be used with patients, while the latter are more commonly for HCPs own information. A majority of HCPs except for midwives do send patients home with printed materials about vaccination.
• HCP respondents' suggestions for how PHAC can assist them in addressing patient vaccine reluctance revolve around 3 key themes: raising the profile of the issue, educating and informing the public, and providing access to printed materials.

It is anticipated that this survey will facilitate evaluation of key PHAC published resources (e.g., NACI statements, the Canadian Immunization Guide) and their role in building capacity in HCPs to address vaccine hesitancy. The survey will also inform the direction of the Centre for Immunization and Respiratory Infectious Diseases (CIRID) programmes, and the Agency will use the survey results to advise programme activity and to establish a baseline for measuring programme effectiveness through a future survey.