Perspectives of primary care physicians on acceptance and barriers to COVID-19 vaccination

Introduction

With emergency use authorisation for COVID-19 vaccines approved in December 2020, there is hope that the virus will become more controlled and a return to normalcy can be achieved. Essential to this goal is vaccinating enough of the population to achieve herd immunity, currently estimated at ≥80% of individuals in the USA.1 However, this concept of achieving heard immunity is changing in respect to COVID-19 due to issues of vaccine hesitancy and uptake and may be unachievable, which is leading some to reorient towards reaching a reasonable level of ‘normalcy’.2 The number of Americans willing to receive the vaccination fluctuated throughout 2020, from as high as 72% in May to 60% in December.3 A recently published (February 2021) systematic review reported a lower acceptance rate (56.9%), indicating that 3 months of vaccine delivery did not result in higher potential uptake.4 COVID-19 vaccine uptake may especially be harder among minority groups (eg, African-Americans) who experience more health inequities.5

To reach normalcy in the USA, all of those who report that they will accept the vaccine will have to do so, and a significant number of those who are vaccine hesitant will have to be motivated to vaccinate. Vaccine confidence and acceptance are largely predicated on trust in the safety and efficacy of the vaccine as well as in healthcare personnel, institutions and public and government officials who shape policies around vaccine dissemination and communication.6 Evidence-based and novel strategies are needed to increase vaccine acceptance, especially in those communities with historical distrust of healthcare professionals or stringent antivaccination beliefs.7 For example, Hildreth and Alcendor8 suggested a multimedia approach using social media, flyers, pamphlets and radio commentaries in multiple languages in order to reach minority groups in the USA. They also propose the use of virtual town halls with community leaders in order to address questions that the general public might have about the COVID-19 vaccine.8

A sizeable body of literature demonstrates that healthcare clinician recommendation is one of the most important factors in decreasing vaccine hesitancy and improving vaccine confidence, thereby improving vaccine uptake.9 10 This finding is borne out in two recent national survey of US adult acceptance of a COVID-19 vaccine.7 11 In the study by Head and colleagues, almost a quarter of respondents (n=739) reported that they would be more likely to receive the vaccine if their healthcare provider recommended it.11 In a national study of 672 participants, the majority of respondents identified “their own physician” as the most reliable source of information about COVID-19.7 It is important to note that vaccine hesitancy in parents when concerning childhood vaccinations has been linked being uncertain on whether they trust their paediatrician and to thoughts that their physician has not provided adequate information on vaccines.12 13

Undoubtedly, many patients will take the vaccine without any need for education, information or encouragement, but the novelty of the COVID-19 virus and vaccine technologies, as well as the speed of development, have the potential to introduce new barriers to vaccination. Furthermore, given that none of the initial vaccine trials enrolled children or pregnant women, and these groups tend to have higher incidences of vaccine hesitancy than the general population,14 15 primary care physicians (PCPs) will be crucial in providing accurate information and addressing patient concerns as the US approaches future phases of vaccine candidacy.16 However, while a few studies have gauged healthcare clinician acceptance of COVID-19 vaccines in general,17 18 no studies to date have explored the perspectives of PCPs on providing the vaccine to patients, anticipated acceptance by their patient population or the sources of hesitancy and concern that they are preparing to address. It is important to note, unless indicated, the authors are including paediatricians as PCPs based on definitions provided by the American Academy of Family Physicians.16

In order to gain insight into these factors, we surveyed paediatricians and family medicine physicians in Texas. Our objective was to understand PCPs’ experiences with COVID-19, their knowledge and willingness to receive the COVID-19 vaccines, their perspectives on their patients’ hesitancy to receive the vaccine and their willingness and reasons for dismissing a patient who refuses the COVID-19 vaccine.

Methods

Results

Of the 676 individuals who opened the questionnaire, 103 did not complete any questions and were excluded from the data analysis. In total, 573 participants were included in the final sample.

Discussion

Based on our results, we expect that the majority of family medicine physicians and paediatricians in Texas will accept vaccination for COVID-19, and most of those will do so as soon as possible. This finding aligns with other studies that show high acceptance of the vaccine among healthcare workers,26 27 but this study is unique as it focuses specifically on the attitudes of PCPs in the USA. A similar study conducted with general practitioners (n=1623) and primary care nurses (n=1055) in Canada, France and Belgium from October to November 2020 found high levels of COVID-19 vaccine acceptance (74.98%).28 Similarly high levels of participants (79.27%) reported that they would recommend COVID-19 vaccines to their patients. The high level of reported acceptance, coupled with frequent vaccine endorsement, including majority intention to endorse COVID-19 vaccination, is crucial as physician vaccine attitudes and recommendation are vital to patient uptake.10 29 Participants estimated patient and community acceptance at rates similar to those reported in national surveys,3 7 30 yet still not high enough to reach herd immunity or a level of normality.2

At the time of questionnaire dissemination, only the mRNA vaccines (Pfizer-BioNTech and Moderna) were candidates for emergency use authorisation.21 While the majority of participants correctly identified these vaccine types, the novelty of the technology warrants increased physician education show that they can effectively answer patient questions, discuss how the vaccines work and address relevant concerns about safety and efficacy.31 Informed approaches will be especially important as new variants arise, more vaccine types become available and more individuals become eligible for vaccination. In terms of dismissal policies, prior research has shown that most physicians do not endorse dismissing patients who refuse vaccines, though the practice has grown over the last decade and is more prominent among paediatricians than family medicine physicians.32 We report similarly low endorsement of dismissal, though our findings are consistent with the few studies that show that dismissal is used to promote clinical safety and reduce disease risk for other patients.33 While COVID-19 is highly transmissible, with a rate of reproduction (R₀) ranging from 1.9 to 6.5,34 and the effects are potentially life threatening, our study suggests that physicians may feel a duty to provide care to their patients and a willingness to assume risks associated with unvaccinated patients.

Our study identified physician self-reported confidence at high levels to respond to specific patient concerns about COVID-19 vaccination. Participants indicated that they felt most confident in situations related to educating patients where factual information might be used to address patient concerns. Specifically, most participants felt confident providing general information about the vaccines and discussing the safety and necessity of vaccination. PCPs and other healthcare professionals have been identified as trustworthy sources of COVID-19 information7 and may be the best situated group to counter misinformation that could dissuade patients from accepting vaccination. A 2021 study of 5 years of Medicare data (2012–2017) found that PCPs provide the most vaccines in the USA,35 which supports that they are both experienced and well equipped to provide COVID-19 vaccinations, immunisation counselling and ongoing clinical guidance to patients. However, others have noted that COVID-19 vaccinations in the USA have mainly been occurring outside of primary care settings, and thus, to encourage the vaccine hesitant to receive the COVID-19 vaccine, vaccination efforts may need to be shifted to primary care in order to take advantage of the trust the PCPs have built with their patients.36

Participants reported that they felt the least confident in responding to patients’ personal or religious objections. In this study, the majority of participants self-identified as having some type of religious affiliation, most commonly a Christian denomination. We did not collect data on the religious preferences or affiliations of participants’ patients, but according to the Pew Research Center, 77% of adult Texans identify as Christian.37 Thus, while there is ongoing debate within the medical and ethical literature about the role of physicians’ spirituality in the practice of medicine,38 it is possible some physicians may choose to have discussions about religion and its impact on vaccine decisions with their patients. However, it is unknown whether comfort level in having such discussions varies by the religion of the physician and patient.

PCPs are ideally situated to deliver guidance and messaging on COVID-19 vaccination. It is important to note that in general PCPs are given little or no training on how to manage discussion of controversial topics with their patients.18 Therefore, providing training on how to address COVID-19 vaccine hesitancy or controversial topics in general may be beneficial to increase vaccination rates. To this end, PCPs may benefit from assistance from professional associations, medical institutions and local governments who provide factual information that they can provide to patients who are considering whether to accept the vaccine. Possible reasons for refusal will likely be diverse and vary by region of the USA, which may necessitate tailored messaging and thoughtful discussions. PCPs should emphasise the benefits of vaccination, including the ability to travel, visit loved ones in nursing homes and achieve a return to normalcy. Messaging should be adapted to physician comfort level, local contexts and patient factors in order to successfully impact vaccine uptake.

Conclusions

We surveyed PCPs in the state of Texas to assess their acceptance of COVID-19 vaccination and their perceptions of patient and community acceptance. The vast majority of the PCPs surveyed stated that they would receive the COVID-19 vaccination when it was available to them and were able to correctly identify the type of vaccines available. We found that PCP confidence to respond to patient concerns about COVID-19 vaccines was fairly high for all of the patient concerns identified. Finally, the PCPs in our study stated they would not dismiss a patient despite not receiving the COVID-19 vaccine, which suggests a commitment to the needs of all patients, including those who choose not to get the vaccine.