Vaccine hesitancy among physicians: a qualitative study with general practitioners and paediatricians in Austria and Germany

STRENGTHS AND LIMITATIONS OF THIS STUDY

  • Qualitative data on the reasons of vaccine hesitancy (VH) among primary healthcare professionals such as general practitioners (GPs) or pediatricians are scarce although they play crucial roles in consulting patients and parents on vaccination decisions. The article provides unique data on the reasons for VH among primary healthcare physicians.

  • From the contacted physicians all those, who agreed to participate, practice homeopathy. Further studies that investigate the link between complementary and alternative medicine (CAM) and vaccine-hesitant healthworkers are needed to find out whether there is a link between CAM and VH of healthworkers.

  • The empirical research data offer unique insights into determinants of vaccine-hesitant behaviour of healthcare professionals and the role of social media in fostering and promoting VH views.

  • Finding vaccine-hesitant GPs was difficult; from 41 contacted ones, only 10 agreed to participate. No participants could be recruited in Switzerland and only one from Germany. This might be due to not wanting to publicly discuss vaccine-hesitant views as they are controversial especially as a healthworker.

Introduction

A key strategy to fight the COVID-19 pandemic has been a fast roll-out of COVID-19 vaccines worldwide.1–3 Yet the pandemic has again shown how important it is to work against the causes of vaccine hesitancy (VH) as a significant threat to sufficient vaccination coverage in high-income countries. While in low-income and middle-income countries (LMIC), supply and delivery of vaccines are determining factors for low vaccination rates in general,4 in high-income countries, VH and/or low demand for vaccines pose the biggest challenge. For example, an international study on COVID-19 vaccine acceptance revealed that people from LMIC are more willing to get vaccinated than those in high-income countries like the USA.5 Despite COVID-19 vaccine rates being generally high in high-income countries, there has been an emerging VH of COVID-19. Reasons for that are manifold and relate to the rise of fake news, or what WHO officially calls infodemic. Furthermore, conspiracy theories fueled a rising VH among people who distrust conventional biomedicine or are dissatisfied with societal/political institutions.6–10 Other studies suggest that about 30% of populations in high-income countries are COVID-19 vaccine hesitant and about the same amount of people are hesitant towards vaccines in general.1 11 12 The WHO SAGE (Strategic Advisory Group of Experts) Working Group on Vaccine Hesitancy, established in 2012, defined VH as a ‘delay in acceptance or refusal of vaccination despite the availability of vaccination.13 The SAGE Working Group also designed a Joint Reporting Form to gather a global picture of VH to see whether it changes. Most countries (>90%) reported the presence of VH; it is not a new phenomenon, but has existed since the presence of vaccines.14 15 Reasons for VH are manifold: fear of side effects, lack of confidence in safety and importance of the vaccine, lack of knowledge and information, anxiety of vaccine, declining trust in health authorities, religious beliefs and different vaccination strategies that would also yield to different amounts of VH in the population.10 16–19 A relatively new factor influencing vaccine uptake and hesitancy is the presence and influence of social media that can lead to a strong polarisation of people for or against vaccination.20 21 Despite the great effort of global vaccination programmes, major outbreaks of preventable diseases such as measles or rubella still occur due to non-sufficient vaccination coverage.14 22 23 In 2017, 90 000 deaths were associated with measles,24 and in 2018, measles-associated deaths increased to 140 000.7 25

While studies show that most healthcare workers (HCWs) are compliant with vaccines in general and COVID-19 vaccine in particular, some other studies revealed that there were HCWs who were hesitant regarding mandatory vaccinations, with many behind with their vaccine schedule or rejecting vaccines.26–33 A study comparing international data on COVID-19 VH among HCWs found that it ranged from 4.3% to 72% (average 22.51)—the biggest concerns for HCWs were vaccine safety, efficacy and potential side effects.34 The trust of health workers in the COVID-19 vaccine was generally high, but it varied according to the different COVID-19 vaccines.33 Another international review study of COVID-19 vaccine acceptance found that health workers’ acceptance was highest in Israel and lowest in the Democratic Republic of Congo.35 While there is some knowledge on the factors influencing attitudes towards VH relating to COVID-19, there are few studies on HCWs who are generally vaccine hesitant.36–38 Most studies indicate that the hesitant groups are more likely to be found in the group of nurses, ethnic minorities and otherwise marginalised groups of HCWs.34 37 39–41 There are few studies on the reasons for VH of physicians who work in primary care settings, such as general practitioners (GPs) or paediatricians. GPs and paediatricians are often the first contact point for vaccination. The GPs’ or paediatricians’ attitudes can have a significant multiplier effect as she/he can influence their patients’ and their patients’ family members’ vaccine behaviour.30 42–44 A study conducted in France in 2015 surveyed vaccination practices and attitudes among GPs and found that up to 43% of the surveyed did not recommend vaccination to their target patients. Another study from Switzerland finds that GPs or paediatricians who also practice complementary and complementary medicine (CAM) are more likely to advise late vaccinations of children.42 43 45

In German-speaking countries, VH or refusal has often been linked to anthroposophical medicine and the reform movement of Rudolf Steiner. For example, it has been suggested by official public media that the low vaccination coverage rates in Germany and Austria are also caused due to the influence that anthroposophical medicine plays on epidemiological concerns in these countries (eg, for Measles vaccination).46 47 The COVID vaccination coverage is still below 70% in German-speaking countries (in Austria, only 56.2% have three COVID vaccines by July 2023, in Germany 62.6% got two or more COVID-19 vaccines by April 2023, in Switzerland, the percentage of the population who got one COVID-19 vaccine is at 69, 76% by November 2023).9 48 49 In contrast, it is much higher in other European countries like Spain or Portugal. Although this link between COVID vaccination and anthroposophical orientation has not been thoroughly investigated through scientific studies, some studies found that people adhering to anthroposophical ideas tend to delay or dismiss vaccination for themselves and their children.50–53 One study found that anthroposophical-oriented physicians perceived infectious childhood diseases as necessary for the psychosocial growth of the child.51 Two recent studies in Austria showed that some physicians and midwives advise their patients to refrain from getting vaccinated or to vaccinate their children later than officially recommended against measles.54 55 The reasons for VH in these studies are multifaceted, though there is a relation between being in favour of CAM (complementary and complementary medicine) and being vaccine hesitant. While these studies focus on the measles vaccine in particular, they found that most interviewed HCWs seemed to be vaccine hesitant in general.

This study is concernced with the reasons for VH of physicians. We aim to understand how and when the HCWs developed vaccine-hesitant views and how and if they transmit these to their patients.

Material and methods

Study design

The study uses an explorative qualitative design with a grounded theory approach following the Standards for Reporting Qualitative Research checklist for reporting qualitative research (online supplemental file 1). The approach suits the question as there are only few studies on general VH of GPs and paediatricians in German-speaking countries—especially scarce in Austria. Grounded theory uses a hypothesis generating study design with open or semistructured interviews and inductive data analysis—codes and categories were extracted from the empirical data material itself. Data analysis is grounded in the material itself.56

Supplemental material

Recruitment

Potential participants were searched for in internet forums, newspaper reports and through personal contacts and snowballing—interview partners were asked to name potential new interview partners.57 In addition to having completed a medical degree and current professional activity as a doctor in a hospital and/or practice, the inclusion criteria for initial contact were a hesitant or negative attitude towards vaccinations, which was assumed, for example, through active membership in associations with the purpose of critical vaccination education or a declaration in that sense on their webpage. Given that vaccine-hesitant GPs or paediatricians are the exception, it was challenging to find physicians willing to participate in a study on VH; 41 potential participants were contacted in Austria (28), Germany (8) and Switzerland (5) via email, letters or over the telephone and 10 (9 Austrians and 1 German) agreed to participate. Getting information and contacts from Switzerland was more difficult than expected and no answer came from the emails and letters that were sent out by KML.

Data collection

An interview guide was prepared following a first literature search on VH that provided ideas for themes to discuss during the interview. As a qualitative study aims to let themes emerge, open questions were chosen on the following themes: professional development, general views on vaccination, continuous education activities and interaction with patients regarding vaccinations (see Box 1).

Box 1

Interview guide, English translation

  • Please tell me about your education and career path?

  • What do you think of vaccination in general?

  • What do you think about your training in relation to vaccinations and infectious?

  • Infectious diseases during your medical studies?

  • How do you feel about the diseases (and their consequences) against which?

  • Vaccinations are used prophylactically?

  • Childhood diseases, fluinfluenza, travel vaccinations?

  • What advice do you give your patients on the subject of vaccinations?

  • How do you educate yourself on the subject of infectious diseases?

  • Where do you get your information from?

The semistructured interviews with GPs and paediatricians in Germany and Austria were conducted by KML for her medical thesis under the supervision of EJ-P and KH between February 2017 and May 2018. The interviews lasted between 35 and 110 min and occurred in the participants’ homes or public places. All participants signed a consent form before the interview.

Data analysis

The interviews were recorded, transcribed verbatim and anonymised by KML. KML and SW inductively coded the material independently using the software atlas.ti following the phases of qualitative content analysis: familiarising with interview data, generating initial codes, searching for broader categories and adding codes, reviewing codes and categories, defining and naming categories and producing a coding report.56 58 59 The broader categories are discussed in the results section. For the purpose of this publication, the quotes were translated into the English language by SW.

Patient and public involvement statement

It was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting or dissemination plans of our research.

Ethical considerations

The need for approval of the study was waived by the Ethics Committee of the Medical University of Vienna (6 July 2016).

Results

Study population

Ten physicians participated in the study. Nine interviews were conducted in Austria (see table 1). The participants were medical university graduates and worked as GPs or paediatricians. Five of them were female, and five were male. They were between 45 and 65 years old. One participant worked in a practice with a social insurance contract, one in a hospital and private practice and eight worked in a single private practice. One interview occurred with a GP in Germany.

Table 1

Interview partner demographic and professional details, time and place: between February 2017 to may 2018, Austria and Germany

Five main themes were identified from the interviews: education and career path, understanding of medicine and the medical profession, experiences with vaccinations, doctor–patient interactions regarding the topic of vaccines, and continuous education activities and the link to VH. These are presented with quotations from the interviews below.

Education and career path: developing vaccine-hesitant views

At the beginning of the interviews, the participants were asked about their career paths and were encouraged to state their opinions on vaccines. Some similarities were found between the interviewed physicians. Early contact with non-evidence-based methods such as homeopathy or anthroposophical medicine during their medical training was found in most interviews:

I started to study, already planning to go into the field of alternative medicine. The reason for that is my own experience with illness. (…) You don’t get to homeopathy with your head. I started with Chinese medicine. I started my studies and wanted to go to China for two years. And in my last year of studies, I stumbled across homeopathy. (P6)

Already at the university, I started with homeopathy training. (P5)

Similarities were also found in the medical careers of the participants, as the majority (eight) ran a private practice (Wahlarzt). As reasons for opening a private practice, participants named personal freedom and more time to dedicate to their patients, making it possible to define an individual treatment plan, including CAM (complementary and complementary medicine).

Understanding of medicine and the medical profession

An aspect most participants shared was a critical appraisal of aspects of conventional medicine.

Conventional medicine is good, it is good to have it as our basic medicine; it is my basis, too. But it is an anti-medicine, meaning you prescribe antibiotics against bacteria, anti—against fungi, against fever; no matter what, it is always something to fight against it; it is never something that supports a process. (Interview 10)

All participants felt the urge to point out their personal perceptions of health and illness when it comes to medical treatment. A ‘different approach’ to health problems was highlighted in all interviews. Conventional medicine and corresponding facilities or methods were blamed for ignoring individual needs and impersonal treatment. Several times, vaccines were named as an example to explain what was wrong with the healthcare system from the participant’s point of view. One participant said conventional medicine was ‘nice to have’ but lacked determining content. Other participants said that vaccines were outdated and, with the right lifestyle or approach to diseases, unnecessary.

A balanced, healthy lifestyle is all you need for disease prevention. To take care of yourself. I’m not talking about a scared, fastidious perception of body signals but a cautious way of perception. Good relationships, a good social environment, and a workplace that doesn’t make you sick just thinking about it. That’s prevention. Besides that, diseases are part of life. (Interview 3)

(…) because for sure—it’s not germs that make us sick but circumstances in life, our way of life. And because of that, vaccines are off-topic. I don’t declare myself an anti-vaxxer because it’s so hard to fight something. But I am in favour of the natural rhythm of the body, that’s what I support, and to that effect, vaccines are unsuitable, yes. (Interview 8)

According to some participants, illness was nothing objective but the immediate result of wrong behaviour. If people took care of themselves and their children—vaccines were not necessary.

Experiences with vaccinations

In the interviews, we asked about negative experiences with vaccinations—either personal ones or regarding patients. Some participants referred to negative side effects as one of their main reasons to object vaccines (Interviews 2, 3, 4 and 8), while others never personally observed side effects (Interviews 1, 2, 5 and 8). One participant had a dramatic experience at the beginning of his medical career almost 40 years ago: one of his patients developed meningitis after vaccination, which he said he then ‘cured with homeopathy’ (Interview 4). Another participant, a paediatrician, said that the reason for the absence of side effects among his patients was his vaccination schedule.

In our practice […] all those side effects don’t occur. We conduct vaccination after the first year of life of a child—at the earliest and only if the parents ask for it. And we don’t do hexavalent vaccines. (Interview 1)

All of the participants had similar points of criticism towards vaccination, although their weighing was different. One critique that most participants shared was the handling of vaccine side effects:

In my experience, side effects of vaccinations in a medical context are often hidden or not considered enough, although there is clear data on it. (Interview 7)

Doctor–patient interactions regarding the topic of vaccines

Other aspects of criticism towards vaccines were the frequency and number of recommended vaccines, neglect or shortage of information, too little information for the patients and the development and composition of vaccines. The paediatricians, for example, were especially hesitant towards the Hepatitis-B vaccine for small children:

Give me one reason why you must vaccinate a child under three against Hepatitis. The children are not sexually active and are not taking intravenous drugs with needles from other users who have hepatitis. These are the only risks. Of course, some mothers could have it, we know that, which is why there are the preventive medical check-ups at the gynecologist […]. (Interview 1)

For me, it really is the timing of the vaccination. Hepatitis B already at infant age is completely absurd. (Interview 10)

Most interviewees do not conduct immunisation in their practice, and some vaccinate little. How participants advise their patients on vaccinations differs a lot: some do not give general advice for or against vaccination but aim to support the decision-making process of the patient or parent, while others advise completely against all vaccinations.

I think that vaccination is neither fundamentally good nor fundamentally bad, but rather I want patients or parents of patients to have the opportunity to decide for themselves what they want and what is right. (Interview 9)

I advise the patient the way I advise you here in that interview, I advise them that the symptom for which they came to see me is the actual healing process and that we should not work against the natural healing process of the body but that we should support it. In that case, vaccination is not an option, I don’t recommend vaccination. I also don’t recommend antibiotics. (Interview 8)

All the interviewees reported that they regularly saw patients vaccinated earlier and were concerned about side effects when they came to their office. They also reported about patients who suffered from vaccine damage and felt disappointed with conventional methods.

Well, many, many patients visit my office because they got turned down before, because no one wants to hear their story, because they get sent away and thrown out of other offices. (Interview 3)

Continuous education and the link to vaccine hesitancy

When asked about continuous education activities on infectious diseases and vaccine-related topics, most participants said one regular aspect was exchanging with other colleagues. Many, for example, were members of an association on individual vaccination decisions, which issues a regular newsletter. The range of continuous education activities was very wide, from physicians who attended many different activities, official ones from the Medical Chamber, to those who emphasised not going to official events about vaccination.

I don’t go to any lecture on vaccination anymore, I cannot stand it. […] There are also these vaccination days, well thanks, I cannot listen to that, how they talk about how important it is and whatever. (Interview 6)

Notably, most participants used the same German-speaking websites and internet forums that could be considered critical to vaccination yet not generally antivaccination. Often-mentioned sources by participants were popular figures in the German-speaking vaccine-critical scene like Martin Hirte and Gerhard Buchwald, and their books were named as important sources by almost all participants;60 61 though some only named them as popular sources among patients—which is why they read it too. Several participants were also active members of a vaccine critical medical doctors association.

Discussion

This study portrays reasons for VH among physicians—in Austria and Germany—both countries were the full vaccination rate against COVID-19 in the population was below 70%. What are the reasons for VH of GPs and paediatricians and how did they develop over time?

Through its qualitative results, the study is able to show the large array of factors that influence VH of healthworkers and how these views effect their practice as medical doctors.

Five main themes were identified from the interviews: (1) The education and career path of the physicians show that most participants already developed vaccine-hesitant views during their medical training, including extracurricular homeopathy training. (2) The participants’ personal understanding of medicine and the medical profession shows that most of them have a critical stance towards biomedicine, which led them to open a private practice to practice homeopathy. The third theme was (3) experiences with vaccines: most of the study participants would not consider themselves antivaccination in general; they would rather frame their views as critical towards the official vaccine schedule and call the latter exaggerated and poorly adapted to the individual. The fourth main topic was (4) doctor–patient interactions regarding vaccines: most participants did not vaccinate in their practice, and some would recommend late vaccination (eg, for children) to avoid adverse side effects of vaccines. This was especially the case among participants with a moderately critical view of vaccinations. The latter do vaccinate their patients, but not according to the official national vaccination plan.62 Although all the interviewed physicians were vaccine hesitant in general, paediatricians stated particular hesitancy of Hepatitis B vaccination for children. Last but not least, our study shows a link between continuous education activities and VH in the participants. (5) Our study participants visited vaccine-critical websites or read particular vaccine-critical publications that foster VH among their readers.

Almost all interviewed doctors were educated in CAM and practiced it, most commonly homeopathy. This fits the findings of other studies examining the relationship of GPs to vaccinations which show a connection between a critical attitude towards vaccines and the practice of alternative methods. The reasons for practicing CAM (complementary and complementary medicine) were dissatisfaction with the public health system, and a critical stance towards conventional biomedicine.7 27 38 63 The private practice allowed the participants to take more time for the well-being of a patient. A lack of time for patient care is a common point of critique both in Austria and Germany, but also in other countries and studies.42 43 54 Other studies support the finding that trust in CAM usually is connected to low levels of trust in conventional biomedicine.7 54 There was a desire among the interviewed doctors to offer the patient an alternative to conventional medical methods. Above all, this alternative implies the factors of ‘time for the patient’ and a ‘holistic view’ of the medical problem. National and international healthcare planning should take this criticism seriously, and interventions should be designed to improve trust in the health system—in order for the physicians to transmit that trust to their patients.16 64

Some interviewed physicians stated that patients consulted them who had had negative experiences with doctors thus far. This not only concerned vaccine-related issues: a general lack of trust, time and the feeling of not being taken seriously during a consultation make patients switch their GP. Studies highlighting barriers between GPs and vaccination-critical patients confirm that GPs sometimes lack empathy for this collective and that physicians use strong language towards their vaccination-critical patients and sometimes even expel patients from the practices.44 65–68 In many regards, the interviewed physicians stated that they gave the patients what they were looking for: listening to them, taking their opinions and fears seriously, dedicating time to them and respecting their autonomy in decision-making.

Interventions and public health measures to improve vaccine uptake usually focus on broad information campaigns stating the vaccine safety or, in the case of COVID-19, even deliberating compulsory vaccination.36 40 Yet our findings suggest that especially unsure or insecure patients would need individual consultation.5 43 More could be done both by public health campaigns and physicians to inform more about the utility of vaccinations.15 69–71 Studies suggest that increasing vaccine education would also increase vaccine uptake,10 and that public health messaging needs to be tailored to the different needs and wishes of target groups.72 Messages highlighting the benefits of vaccines could also increase vaccine uptake, especially in the part of the population that is undecided about whether or not to get a vaccine.17

Especially since the COVID-19 pandemic, where a rapid infodemic was observed, studies showed that healthcare providers can raise awareness and engage in dialogue with people for example via social media.8 44 73–75 Yet that can go in both directions: pro and contra vaccination. Our sample suggests that vaccine-hesitant HCWs shared that view with their patients and with an online community of vaccine-hesitant health workers. Studies found that, especially on social media, much content on vaccines had an antivaccination attitude and that this content could negatively influence intentions to get vaccinated.74–76 Xie and colleagues found in a review that during COVID-19, there was a user polarisation regarding the vaccine.21 This finding implies that it would not only be necessary that the government or supranational health organisations invest in media and especially social media campaigns to raise awareness for the benefits of vaccines for the general public but also to offer (social) media training to HCWs. Finding global strategies against antivaccine content on websites and social media is adamant.77 Studies suggest removing antivaccination content on social media platforms through coordinated action or fostering partnerships between health agencies and social media platforms, for example, by promoting the content of public health bodies such as the CDC or the WHO.47 48

Strengths and limitations

Qualitative data on VH among primary healthcare professionals such as GPs or paediatricians are scarce, although they play crucial roles in consulting patients and parents on vaccination decisions. The article provides unique data on the reasons for VH among primary healthcare physicians. The empirical research data offer unique insights into determinants of vaccine-hesitant behaviour of healthcare professionals and the role of social media in fostering and promoting VH views. From the contacted physicians, almost all those who agreed to participate practiced homeopathy. As this is a qualitative study, the sample size is too small to be representative. However, further studies that investigate the link between CAM and vaccine-hesitant health workers would be needed to find out whether there is a link between CAM and VH. Finding vaccine-hesitant GPs was difficult; from 41 contacted ones, only 10 agreed to participate. No participants could be recruited in Switzerland, and only one from Germany. This might be due to not wanting to publicly discuss vaccine-hesitant views as they are controversial, especially as a healthworker. The contacted doctors based in Switzerland did not differ in their characteristics from the ones living in Austria and Germany in terms of specialty or propositions. Some of the doctors contacted in Switzerland also offered complementary medical methods and corresponded to the profile of those contacted in Austria and Germany. One difference is that due to a different insurance model, Swiss medical practices are not divided into private and public/or with insurance contracts. Medical services provided in a practice are billed to the health insurance company, and additional services are financed by the patients themselves.78 Almost all interview partners were private GPs/paediatricians and only one worked with a contract with a social insurance. Among the participants, all but two are practicing homeopathy. It makes sense that the majority operates a private practice, as homeopathy services are not reimbursed by social insurance either in Germany or Austria. The result that most participants were not against vaccines per se but instead portrayed themselves as hesitant might also be due to social acceptance. It is not well regarded as antivaccination, especially as a medical doctor.

Conclusions

Our study shows that it is vital to understand the reasons for VH among HCWs to be able to tackle the issue. More studies are needed to debunk if and how there is a connection between complementary and CAM and vaccine-hesitant views of HCWs. To be best prepared for future epidemics or pandemics, more must be done on national and international public health levels to increase education about vaccines and infectious diseases among health workers and the general public. Public health strategies to tackle antivaccination attitudes on the internet and social media are crucial because much of the networking activities of vaccine-hesitant HCWs happen online today. On another level, our study shows that primary healthcare physicians should be made aware that they could positively impact undecided patients and parents regarding vaccine decisions through time and empathy dedicated towards their patients.

Data availability statement

Data are available upon reasonable request. The data sets (anonymised interview transcripts) used and analysed during the current study are available from the corresponding author upon reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants, but the need for approval of the study was waived by the Ethics Committee of the Medical University of Vienna (date 6 July 2016). Participants gave informed consent to participate in the study before taking part.

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