Healthcare professionals’ perceptions of challenges in vaccine communication and training needs: A qualitative study

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Anderson, Aishmita Biswas, Amanda Garrison, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4011945/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Jul, 2024 Read the published version in BMC Primary Care → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Healthcare professionals (HCPs) can play an important role in encouraging patients and their caregivers to be vaccinated. The objective of this qualitative study was to investigate HCPs’ perspectives on challenges in vaccine communication and unmet training needs in this domain. Methods: Semi-structured interviews were conducted with 41 HCPs (mainly nurses and physicians) with vaccination roles (23 in England; 18 in France), gathering information on: (1) HCPs’ approach to vaccine conversations with patients; (2) Challenges of communicating about vaccines; (3) Vaccine-related training and learning resources available to HCPs, and ; (4) HCPs’ training needs around vaccine communication. Results: HCPs described a range of communication experiences that indicated insufficient time, information, and skills to confidently navigate difficult conversations with vaccine-hesitant patients. Communication skills were especially important to avoid conflict that could potentially damage the patient-provider relationship. Some HCPs interviewed had received communication training, but for most, this training was not specific to vaccination. Although general communication skills were transferable to vaccine conversations, most HCPs welcomed specific training and informational resources to support countering patients’ misconceptions or misinformation about vaccines. Conclusions: HCPs would benefit from training tailored to address vaccine communication with patients, and this should be part of a systemic approach that also provides time and space to have effective vaccine conversations. vaccine communication healthcare professionals skills training vaccine hesitancy vaccine confidence Background Healthcare professionals (HCPs) fulfil an important role not just in vaccinating the population, but also in informing patients and caregivers about the benefits and risks of recommended vaccines and addressing their concerns about vaccination. Effective communication is critical to increase patients’ knowledge and acceptance of vaccine offers. Most people view HCPs as are a major and trusted source of vaccine information (Charron et al., 2020 ; Eller et al., 2019 ; O’Leary et al., 2018 ), who can offer reassurance and positively impact vaccine decision-making (Leask et al., 2012 ; Opel et al., 2015 ; Paterson et al., 2016 ). HCPs thus need to be adequately prepared for their communication role and the challenges that may arise as part of it, for example, when speaking with hesitant patients (Donovan & Craig, 2018 ; Verger et al., 2022 ). There are several challenges in mobilising HCPs to proactively recommend vaccination. First, HCPs’ own attitudes towards vaccines can impact whether they recommend vaccines to patients (Bianco et al., 2014 ; Garrison et al., 2023b ; Yaqub et al., 2014 ; Yeung et al., 2016 ). Even if HCPs are themselves in favour of vaccination, their personal attitudes may conflict with their desire to enable patient autonomy (Holt et al., 2016 ; Loftus et al., 2021 ). HCPs may be themselves uncertain (Verger et al., 2022 ), especially when they need more up-to-date information to reassure themselves of the benefits and costs of newer vaccines (Paterson et al., 2016 ). Second, HCPs need relational skills in addition to factual knowledge. These include skills for conveying knowledge in a participatory, non-judgemental manner that displays empathy and maintains the patient-provider relationship (Connors et al., 2017 ), and skills at debunking misinformation that patients may believe (Tafuri et al., 2014 ). Training needs to address vaccine communication challenges have previously been identified in primary and secondary care settings (Berry et al., 2017 ; Lip et al., 2023 ; Lucas Ramanathan et al., 2022 ; Sarnquist et al., 2013 ; Vorsters et al., 2010 ; Williams et al., 2020 ). Several training interventions to promote tailored, participatory communication in vaccination-related consultations have been developed and reviewed in recent years (Leung et al., 2019 ), for example, Motivational Interviewing (Gagneur, 2020 ), the announcement approach (Brewer et al., 2023 ), and the Empathetic Refutational Interview (Holford et al., in press). Yet these interventions have not been systematically rolled out in HCP training programmes (Vorsters et al., 2010 ). This could be because communication interventions are not always converted into accessible training or resources for HCPs (Karras et al., 2019 ). It could also be because communication skills are not often prioritised in medical training, except on very sensitive aspects of medicine such as announcing a diagnosis of cancer (Rotthoff et al., 2011 ). Indeed, vaccination training has typically focused on vaccine knowledge and practical skills required to deliver vaccines (Sherris et al., 2006 ). In addition, communications training tended to target the informational content of the communication (e.g., risks and benefits of vaccines that one should tell the patient), rather than the style (e.g., using empathetic language and tone to deliver that information; Lanza et al., 2023 ; Public Health England, 2018 ). There is a research gap regarding HCPs’ training needs around identifying and addressing patients’ main barriers to vaccination (Lanza et al., 2023 ), which this qualitative study addresses. Our objective was to explore HCPs’ experiences and perceptions of the vaccine communication challenges they faced, what training they had received to prepare them for these challenges, and what training needs remained. Method The research received approval from the ethics committees of the authors’ institutions [blinded]. The research was conducted in accordance with the ethical principles under the Declaration of Helsinki. All participants gave informed consent prior to participation. Setting We focused on HCPs in England and France who hold vaccination roles (i.e., including at least one of the following tasks: recommending, prescribing, discussing, or delivering vaccination) to explore training provision and experiences under two different health systems. In England, vaccination involves a range of professionals (including, for example, nurses, midwives, pharmacists) in prescription, recommendation, discussion, and delivery of vaccination (UKHSA, 2020). In France, vaccination has been mainly carried out by General Practitioners (GPs), but in the last decade, the authorities gradually extended the role of prescribing and delivering vaccination to other health professionals who have undertaken advanced studies (e.g., nurses, pharmacists, midwives; Légifrance, 2022 ; Verger et al., 2015 ). In England, the national vaccine training syllabus recommends communicating with patients, but this is only taken as guidance and need not be offered in practice (Public Health England, 2018 ). In France, vaccine communication is a compulsory aspect of physicians’ medical training and clinical examinations, but how the training is delivered is left up to each medical school (Kernéis et al., 2017 ). Nurses in France undergo compulsory training that includes 4–5 hours of vaccination theory during three years of medical studies, with practical training on recommending and administering vaccines completed during medical placements (Bourquin, 2021). Recruitment of participants HCPs whose roles involved vaccination (i.e., at least one of the following: prescribing, recommending, discussing, and/or delivering vaccination) were invited to take part, with recruitment aiming for a range of ages, genders, professions, and settings (in England, different geographical regions; in France, rural or urban settings). Participants were offered compensation for their time (£20 shopping vouchers in England; €50 in France). In England, participants were recruited via email from a mailing list of 104 previous participants (response rate = 22%) who had agreed to be contacted for interviews after completing an earlier study on vaccination attitudes and behaviours (Garrison et al., 2023b ). In France, participants were recruited by contacting General Practitioners (GPs) through publicly available list-serves, asking participants to share invitations with colleagues, and requesting the Regional Union of Healthcare Professionals for Nurses (UPRS Infirmières) to send out invitations. Seventy invitations were sent to HCPs in southeastern France (response rate = 25%). Recruitment in both countries continued until the researchers agreed that an appropriate range of healthcare professionals were represented and reasonable data saturation to meet the main research objectives had been achieved (Shaw et al., 2019 ). Consent and interview procedures Prior to the interview, participants were sent an information sheet and consent form electronically. Participants returned the signed consent form electronically or verbal consent was obtained during the interview. All interviews were held over video- or tele-conferencing and audio-recorded. Semi-structured interviews were conducted in English and French by experienced qualitative researchers with the appropriate language skills ([blinded]). Interviews were planned to take between 30–60 minutes, following a topic guide that specified key question areas and prompts for interviewers (see Supplemental Material). Data Analysis All interview recordings were transcribed verbatim. French transcripts were translated into English by an English-speaking researcher fluent in French ([blinded]) with the assistance of two native French speakers ([blinded]) where necessary. We followed familiarisation steps in thematic analysis protocols (Braun & Clarke, 2006 ): at least one researcher from each team ([blinded]) read all transcripts from their country to understand the data and identify potential themes in the transcripts. Based on this preliminary analysis, the research team created a framework to systematically analyse the transcripts with respect to four domains relevant to understanding HCPs’ vaccine communication training needs and provision (Table 1 , column 1). Two researchers ([blinded]) then read and coded all transcripts with regards to the initial framework, with additional themes identified and added after discussion. Coding was completed using NVivo 13 (Lumivero, 2020 ). To ensure consistency in coding, the two researchers first independently coded the same four transcripts (10%) and discussed them to reach consensus. Two rounds of independent coding and review were completed, first to reach consensus on the four domains, and then on the themes identified within the four domains. All coding discrepancies were resolved through discussion and the framework was updated iteratively between rounds of discussion to improve consistency of interpretation. Thereafter, the remainder of transcripts were coded individually by [blinded] and [blinded], who met regularly throughout the coding process to discuss any uncertainties. Table 1 Themes from four domains related to HCPs’ vaccine communication and training needs Domain Themes 1. HCPs’ approach to vaccine conversations A. HCPs’ perception of their communication role. B. Informational content of the conversation. C. Communication styles HCPs use in vaccine conversations. *D. HCPs’ perception of the experience of vaccine-related conversations with patients. 2. Challenges HCPs face in vaccine communication A. Difficulties in addressing misconceptions/misinformation and/or changing patients’ minds. B. Lack of information, including lack of up-to-date information to give patients. C. Needing time and space to have the conversations. D. How communication skills can help in difficult conversations. E. Needing to maintain relationships with patients and avoid conflict. 3. Vaccination-related training and learning among HCPs A. Existing training coverage (including how and what ). B. Experiential learning (from peers and work experience). C. Official information sources consulted. *D. Perception of informational resources. 4. HCPs’ perception of existing communications training A. Perceptions about content of existing communications training. B. Perceptions of different training formats (e.g., face to face, online). C. Perceived relevance of existing communications training. D. Gaps in training (including if this type of training is not offered). *Indicates themes added to the initial analysis framework after discussion during the coding process. Results Between July to November 2022, we interviewed 41 HCPs from England ( n = 23) and France ( n = 18). Socio-demographic characteristics can be found in Table 2 . Table 2 Sociodemographic characteristics of interview participants. Number (%) Characteristics France ( n = 18) England ( n = 23) Total ( n = 41) Profession General practitioner (GP) 8 7 15 (37%) Nurse 9 15 24 (58%) Other* 1 1 2 (5%) Sex Female 9 17 26 (63%) Male 9 6 15 (37%) Age ≤ 30 years 5 3 8 (20%) 31–49 years 7 7 14 (34%) ≥ 50 years 6 13 19 (46%) Region (England) East of England - 8 - South East - 4 - London - 2 - West Midlands - 3 - South West - 6 - Region (France) Rural 4 - - Urban 14 - - Note. *Other = pharmacist (France) and community health worker (England) Table 1 shows the final themes identified through thematic analysis of the transcripts. The results presented below summarise the key issues that relate to HCPs’ vaccine communication with patients and their unmet training needs, organised by the four domains and their main themes. We illustrate each theme with quotations that concisely represent typical responses of interviewees from both countries. HCPs’ approach to vaccine conversations Perception of communication role. All HCPs recognised vaccine communication was part of their role. Many felt that they needed to provide information for patients to make their own informed decisions on vaccination. Before taking a position or not, we need to first simply inform that there is this or that vaccine, that certain ones are mandatory, some are recommended, that some are reimbursed, some are not…and then according to the reception of this information, [we have] an advising role. ( P04, Male, 41, GP, France ) Most HCPs discussed communication in the context of recommending vaccines to patients and answering their questions about vaccines, but several also highlighted that they discussed vaccination outside of their patient-facing roles, for example with family, friends, and colleagues: I had members of my family even who were against it…but they asked me often about what I thought and to explain [vaccination] to them. ( P16, Female, 26, GP, France ) Informational content of conversation. HCPs often described using scientific and medical information to inform and correct misconceptions. I tried to stay with arguments that have a bit of scientific proof...even looking up in front of them studies that show the decrease in incidence of the disease since vaccination began. ( P15, Male, 35, GP, France ) HCPs would also explain to patients why vaccination was beneficial from an individual as well as collective standpoint. I will talk about the benefits of having the vaccinations to protect baby from infections, pros and cons and that sort of thing with new mums. ( P28, Female, 42, GP, England ) Some HCPs also mentioned that they would share personal experiences and anecdotes when they felt this information was relevant to encourage their patient to be vaccinated. I tell them that I was sick. That I was almost on a ventilator, because they see me as someone who is strong…a solid guy, a doctor. Someone who isn’t fragile. ( P12, Male, 67, GP, France ) Communication style. Many HCPs were comfortable with initiating conversations about vaccination and encouraging their patients to be vaccinated. I try to promote actively vaccinations to everyone, every patient, children and adults and I use that in every contact that I have in the surgery. ( P20, Male, 46, GP, England ) However, some HCPs felt uncomfortable if the patient was hesitant and would refrain from pursuing the subject of vaccines further. I didn’t respond [to the patients’ concern], in fact. I knew that the communication was complicated, and so if they asked me questions, I responded, but after, I left them to their beliefs. ( P11, Female, 41, Nurse, France ) When speaking with hesitant patients, most HCPs highlighted the need to respect patient autonomy in their vaccination decision. For some, this meant remaining neutral at the beginning of the conversation. I try not to push them in either direction, I just give them the information and just say, if you would like to have these vaccines then just make an appointment. (P22, Female, 33, GP, England) For others, respecting autonomy meant letting the patient make the ultimate decision but still trying to support them with that decision. Even if for me, [although] I find [it] a shame to not vaccinate…from the moment that [patients] are aware of the risks…we listen and try to help them with their choice while respecting their wish to not get vaccinated. ( P08, Male, 42, Nurse, France ) Some HCPs from England reported encouraging patients to look up reliable information for themselves. This approach was not mentioned by HCPs in France, although they discussed similar goals of providing reassurance, information, and explanations about vaccines. My approach is to reassure them, show them the information we have got and with pregnant women I’ve found a link to a podcast which I thought they might like to follow up on. ( P19, Male, 62, Nurse, England ) Some HCPs described communication techniques they had been trained to use, for example, counselling skills, how to listen, ways to tailor information, and the use of analogies. The purpose of these techniques was to reflect empathy and openness towards their patients. It’s about listening and about hearing what that objection is and then to try and relate it to the current day. ( P36, Female, 64, Nurse, England ) Perception of vaccine conversation experience. HCPs described some vaccine conversations as “difficult” and “unpleasant”, in which they faced challenges in vaccine communication detailed in the next section. In contrast, other vaccine conversations were described as “easy” and “comfortable”. In these conversations, patients listened, HCPs had a good relationship with the patient, and HCPs had confidence in their own communication skills and felt prepared for the conversation. You think beforehand [of] all the scenarios of what you might be asked. That’s how…in the conversation I didn’t feel challenged. I think [the patient] was quite happy to receive [the information]. ( P27, Female, 52, Nurse, England) Challenges in vaccine communication Difficulties in addressing patients’ misconceptions and fixed beliefs. HCPs described various challenges they faced when patients displayed resistance to vaccines. This was generally in response to the HCP’s recommendations, but a few HCPs had also faced challenging patients who arrived for their vaccination upset about vaccination mandates (e.g., for travel or professional purposes). There are a lot of people who did [vaccination] really for professional reasons. It is [these] people who would come and be angry. ( P10 , Female, 56, Nurse, France ) HCPs described some of the doubts and concerns of their patients as legitimate, but others they considered irrational. For example, HCPs appreciated their patients’ logic for declining vaccination. Those [patients] that believe that the data is not sufficiently robust enough and don’t wish to be part of a large experiment until they’ve got longer term data…we’ve peddled that line ourselves with new drugs and new technologies all the time. So, although it’s not a position that I think is the most sensible, it is a logical position. ( P23, Male, 52, GP, England ) In other instances, HCPs questioned the reasoning that some patients used to reject vaccination. [The patients’] reasons were fear of needles and they were covered in tattoos…so there’s some warped perceptions of what they’re prepared to put themselves through or not. ( P41, Female, 57, Nurse, England ) HCPs were able to detail some misconceptions patients had about vaccines, which many HCPs identified as coming from unreliable information sources such as social media. The paradox is that they have more confidence in Facebook groups than in studies. ( P01, Male, 25, GP, France ) One HCP reflected that even credible information sources could be misinterpreted by people without the right expertise. Without the real expert understanding and knowledge and everything that happened behind that, in some ways [the sources] are more dangerous than they are informative at times. … [The patient] read a BMJ [British Medical Journal] paper…She basically found what we’d call credible evidence, but then came to her own conclusion about it. ( P36, Female, 64, Nurse, England ) The most difficult experiences cited included patients with religious objections and conspiratorial beliefs. In extreme cases patients became aggressive, accused HCPs of being part of the conspiracy and of wanting to harm children with vaccinations. That is also the problem, that they think so much about the conspiracy that you give an argument in favour of vaccination and they envelop you in the conspiracy. (P01, Male, 25, GP, France) Many HCPs recognised that hesitant patients’ mindsets could be difficult to change. Some HCPs found this resistance to change challenging and were discouraged from continuing vaccine conversations with these patients: From the moment I understand that no matter what my response [is], it will not change their way of thinking...I let it go. ( P02, Female, 52, GP, France ) Others displayed confidence and willingness to engage with patients with such mindsets nonetheless, reflecting that the conversation might still do some good. The people of that cohort are usually of a fixed mindset and it’s quite difficult to shift that, and we hope that having that conversation may make them shift it. ( P21, Male, 33, GP, England ) Lack of information to give patients. HCPs most commonly discussed lack of knowledge and uncertainties in how to respond to concerns in the context of COVID-19 vaccination programmes. Particularly at the start of the vaccine roll-out, HCPs struggled with the lack of official information resources to support evidence-based conversations with patients and delays in receiving official government advice. HCPs had encountered conflicting information that contributed to their uncertainties in responding to patients and felt that reliable information was often obscured amidst large amounts of false information on the Internet. What made me uncomfortable was also that I didn’t have enough information… [patients] would say “okay, tell me what are the side effects, there are women who aren’t able to have children any more” and I was uncomfortable because I didn’t really know how to respond . (P09, Female, 57, Nurse, France ) Two HCPs from France also had doubts about the necessity of COVID-19 vaccine for some of their patients. As a citizen, I do not really agree with vaccinating the youngest [against COVID-19], for example. ( P14, Male, 52, Nurse, France ) A more general information deficit for some HCPs was the lack of convincing counterarguments for patients’ misconceptions, particularly when these concerns were motivated by misinformation or conspiracist beliefs and patients did not believe the factual information the HCP had provided. She was saying how she was reading conspiracy theories online. I didn’t really know how to address that one, but I was just trying to say to her, “It is effective, it does go through all these clinical trials, so it is very much safe.” ( P32, Female, 29, Nurse, England ) Needing time and space for vaccine conversations. Some HCPs highlighted the substantial time it took to respond to patients’ doubts and concerns about vaccines. This was especially challenging for HCPs working in primary care. Often they reported having short consultations where the principal focus was not vaccination, leaving limited time to dispel vaccine misconceptions or engage in a convincing discussion with hesitant patients. I don’t have the time built into my consultations for it…if they’re coming for something else, to then add that on to the consultation that’s another 10 minutes and I’ve got another patient waiting so it’s quite tricky. ( P28, Female, 42, GP, England ) Some HCPs in England shared experiences where their organisations had implemented effective solutions to make time for vaccine conversations. These generally involved creating opportunities for patients to speak with a medical professional, for example: … having chats with patients rather than bringing them in on the fast-paced in/out clinics…being able to have time with patients provides a more positive reinforcement and outcome for the patients and their experience with having the vaccine. ( P33, Female, 27, Nurse, England ). How communication skills help with difficult conversations. HCPs shared some of their strategies to try and reach positive outcomes when they engaged in challenging vaccine conversations. A variety of communication skills were described, for example positive non-verbal communication and active listening to clarify the patients’ concern and enable the HCP to adapt their response to the patients’ needs. It’s about that paraphrasing…so that you understand what the actual concern is before you answer them, because otherwise you’re just assuming what their anxiety or fear is about rather than finding out. ( P29, Female, 56, Nurse, England ) Many HCPs would remind patients of their autonomy and tell the patient they respected the patient’s choice. In some cases, this meant the HCP did not pursue the conversation any further, or would tone down their vaccine recommendations for vaccine hesitant patients whom they thought would react poorly to strong recommendations. I know through experience that that doesn’t serve any good to take a strong position that could seem condescending to people who, they themselves are against vaccines. ( P04, Male, 41, GP, France ) The ability to adapt the conversation to the patient was also described as particularly important when speaking to patients who were ambivalent with regards to accepting vaccination. There are things to put in place and things to say and things to not say…to adapt the discussion…to explain to those who are “convincible”…I think there are people for which there are arguments and things can be done to bring them onto the side of vaccination. ( P15, Male, 35, GP, France ) HCPs agreed that despite their importance, developing effective communications skills was challenging. Some HCPs mentioned professional experiences and training that helped develop these skills, but they recognised that not all their colleagues had the skills to communicate well. Some vaccinators can’t do that [communicate well] so I don’t think they’ve given the best experience [to patients]. ( P38, Female, 66, Nurse, England ) A need to maintain patient-provider relationships. Many HCPs highlighted trust as an important component that facilitated vaccine conversations with patients by increasing patients’ receptivity to the HCP’s vaccine recommendations. Providing continuing care and getting to know patients on a personal level was one way to develop this trusted relationship. I think it helps if you have got a relationship with that patient already. If they know you and trust you, if you say things to them, they’re much more likely to hear them. ( P39, Female, 51, GP, England ) Some HCPs described how communication skills helped to build trust, for example by ensuring the environment was conducive for the conversations. It is how you use your body language, how you talk to them and it is just general interaction. … We have got an area where we can actually take them [we talk] one to one and not in a public space. I’m coming around to chat to them face to face, to break down any barriers because when you’ve been sitting behind a table it looks like you are superior and you are telling them what to do. ( P19, Male, 62, Nurse, England ) Although HCPs believed that trust was helpful for effective vaccine communication, it could in some circumstances also be counterproductive. It is good because they trust us, and so that helps to speak openly, but sometimes what is bad is that because they treat us like family, sometimes they don’t listen to us. ( P06, Male, 37, Nurse, France ) HCPs’ prioritisation of maintaining a trusted relationship could also lead them to avoid giving certain information or back away from discussing vaccines if they sensed patients were unreceptive or that the conversation would take too much time. HCPs mentioned not wanting to get into arguments or damage existing relationships by enforcing their own beliefs about vaccines, particularly as vaccination was only one aspect of their care relationship with their patients. You can only try so far and then you can tell if you’re starting to alienate them and you’re affecting your relationship with them so I think you just have to respect their decision…you do have to back off. ( P30, Female, 65, Nurse, England ) Vaccination-related training and learning Existing training coverage. All but one of the HCPs interviewed described receiving practical training to administer vaccinations. This focused on procedures and techniques of vaccine delivery, including obtaining informed consent, in addition to information about how vaccination works, the contents of different vaccines, and their country’s vaccination schedule. Many HCPs in France described vaccination-related modules they had completed during their initial professional training, while many HCPs in England mentioned vaccine-specific training that was available before taking up vaccination roles. Most training was on vaccine theory and practical aspects; only a few HCPs mentioned their courses tried to address discussions with vaccine-hesitant patients. It was just theory when we talked about [vaccines], when we were in school. That was several years ago and now, [there is] nothing in particular for vaccination. ( P17, Female, 47, Nurse, France ) Some HCPs described training they had received around communicating with patients, mostly in the context of their other professional roles and not specific to vaccines. I actually did the Diploma in Child Health…so I’ve done that sort of communication skills and the knowledge that you need during [that] training. ( P23, Male, 52, GP, England ). In France, a few HCPs highlighted motivational interviewing training that was available at an early career stage (though it was not only targeted at vaccination). During [my] internship, I followed a training about motivational interviewing…that can also be used, for example, for tobacco. (P03, Female, 28, GP, France) Experiential learning. HCPs mentioned that learning took place without direct instruction during their professional training. Most of these HCPs had been in the profession for decades and they felt the many patients they had spoken to over the years helped them to gain transferable expertise with patient conversations. I was a surgical nurse for quite a number of years…we would have to impart bad news…so actually you learn those communication skills. ( P31, Female, 50, Nurse, England ) Professional peers were also a source of experiential learning for HCPs, as HCPs picked up skills from watching their supervisors and colleagues. I think the team in the whole are quite skilled at communicating…and then the new staff coming through hear those conversations all the time so they learn from it. ( P37, Female, 51, GP, England ) HCPs also described useful opportunities for discussing best practice with peers, for example in forums with other HCPs. Pharmacists were highlighted as good colleagues to learn from as they had good knowledge of vaccines and, specifically in France, often spoke to patients. We were in contact with pharmacists because they were our intermediaries [with patients]…the pharmacist would say, “oh well if you have all of these doses do it this way.” (P07, Male, 57, Nurse, France) Official sources of information consulted. HCPs tended to seek out information on vaccines for their own knowledge and to use in consultation with patients, as a form of self-directed learning. Most explicitly mentioned using “reliable information” coming from national public health organisations (e.g., in England, the National Health Service “NHS”; in France, the national health insurance fund website “AMELI”, regional health agency “ARS”, and expert health authority that recommends vaccines “HAS”). We made it very clear that we would only access information from two places [the government and the NHS], and if there was any wealth of information elsewhere, we would just simply acknowledge it but we wouldn’t use it ourselves in sharing to others.” ( P21, Male, 33, GP, England ) In England, many HCPs explicitly cited the Green Book (the official government resource for vaccination procedures in the UK), with most describing it as “their bible”. Some HCPs also used the Internet to search for specific information; others discussed information they got from news media, professional bodies (e.g., French Society of Infectious Diseases), independent organisations (e.g., Oxford Vaccine Group), scientific publications, and pharmaceutical companies. Perception of informational resources. HCPs had differing views on the usefulness of information they had access to about vaccination. A few felt they were too busy to look through the information and that it would be helpful if it could be summarised. We receive the Revue du Praticien 1 at the practice but I admit I absolutely do not have the time to look into it. ( P02, Female, 52, GP, France ) The Green Book (the resource for UK vaccination) was specifically highlighted as a useful resource because it was “ incredibly well organised and contains the right amount of actual research and also stating the facts simply but not too much complex detail that it’s not easy to understand ” ( P35, Female, 25, Nurse, England ) and provided “ a framework for knowing what I need to talk to [patients] about ” ( P23, Male, 52, GP, England ). With regards to information resources to share with patients, HCPs felt they lacked lay information that they could give directly to patients. Some HCPs felt that the official vaccine information leaflets that were provided for patients were unsuitable. I think the leaflets that are there trying to explain to the patients in layman’s language about the vaccine…I’ve never liked them … I think it’s a bit too much sometimes…it is a lot of information—I’m not sure who is going to read that. I think it can be a bit more simple probably. ( P20, Male, 46, GP, England ) However, others mentioned that they could find appropriate information for their patients on official websites such as that of the NHS. [The information was] broken down into easy to digest chunks...I think it presents it in quite a logical manner without there being too much information overload. ( P22, Female, 33, GP, England ) HCPs’ perception of vaccine communication training Content of existing communications training. Some HCPs gave details of vaccine communication training they had either attended or knew about from colleagues. For example, one described a COVID-19 vaccine training module where “ there was a brief aspect to the module where it goes on to say when people are not sure about having the vaccine, these are the things that you can say to encourage uptake ” ( P21, Male, 33, GP, England ). Another mentioned that motivational interviewing for vaccine conversations was “ something that is new that is now proposed as a training module when we are interns ” ( P41, Male, 41, GP, France )—although it should be noted that such vaccine-specific communications training for medical interns is still not compulsory in the French system. More commonly, HCPs described communication training they had received as students or in the context of other professional roles rather than as preparation for their vaccination duties. This training covered skills that were transferable such as how to involve patients in their own care, how to convey bad news to patients, and how to navigate tricky conversations with people. We had some sessions of practical situations with complicated patients. But…it was about other subjects, like about antibiotics for example, or announcing a serious disease. ( P16, Female, 26, GP, France ) HCPs described the use of role plays and practical situations in their general communication training to simulate patient scenarios, direct instructions about what facts to give patients, and sessions where trainees had discussions and sharing of experiences. Formats of existing training. HCPs described a variety of training formats they had experienced, including webinars, seminars and conferences, online modules, and workshops. HCPs acknowledged that different training formats had their merits and drawbacks. Online training was generally seen as more accessible, allowing HCPs to schedule it into their day without needing to travel to a training location. One advantage of online training (specifically, “e-learning”) was its ability to be self-directed so individuals did not need to be present at a fixed time and could go through materials at their own pace or repeat learning content. In some cases, it could also be designed to be interactive. I quite like it when it's smaller blocks, and when it has lots of pictures. I like lots of videos and animations and things like that…I learn much better that way.…I quite like that after each section you are tested as well on it, because that helps to cement it in place. ( P40, Female, 51, Nurse, England ) However, when this type of training was limited to an online presentation, some HCPs questioned its utility. Half the time it's going in one ear and out the other, and by the time [one goes] back to work it's like, “Well, what did I learn?” ( P33, Female, 27, Community health worker, England ) Although face-to-face training presented logistical challenges, many HCPs felt that it was more enjoyable and provided more opportunities for interaction and practice through various exercises. I think it was good to have a training with role playing and the trainers who explained things well, it was better than learning in books. ( P05, Female, 27, GP, France ) Relevance of existing communications training. Most HCPs who had experienced training related to vaccine communication felt that it was relevant and helpful to their roles and they had subsequently put it into practice. I think educating yourself, learning and updating yourself with the latest information, that really gives you the confidence, because you can then impart that information to the patients. ( P40, Female, 51, Nurse, England ) Some HCPs felt that it was more useful to target the communication style (e.g., how to approach patients) and include practical exercises, as opposed to just providing informational content (e.g., what to say). It's always been, “This is the spiel I give them but the best thing you can do is have a read of the leaflet, and then figure out on your own.” When you hear things like that you think, I don't quite like the feel of that. ( P33, Female, 43, Nurse, England ) HCPs in France who had undergone Motivational Interviewing training (for patient communication in general) described how they had put that training into practice. I think that [it] helps me sometimes when I don’t have arguments or I feel that the patient is a bit upset, I try to use the basics of the motivational interview to get back on track. And that works pretty well. ( P05, Female, 27, GP, France ) HCPs who had described communications training in the context of other roles also felt that training had relevance to their vaccination conversations. You want to be able to have an engaging conversation and make sure people walk away from it feeling positive. So, having done that training before about managing challenging conversations has definitely been helpful in my role as a vaccinator. ( P32, Female, 29, Nurse, England ) Gaps in vaccine communication training. The main training gap identified by the majority of HCPs was that vaccine communication was often not covered. Never in our training as vaccinators did they say, “This is how you address this, if a person says this,” so [vaccine communication] was just something that I was just a bit unsure about. ( P32, Female, 29, Nurse, England ) HCPs felt that their existing training focused on vaccine knowledge but “ they don’t tell you how to sit and talk to a patient ” ( P26, Male, 65, Nurse, England ). HCPs expressed the desire to have such training, so they could learn new things, refresh their knowledge, and increase their confidence. You never know what's going to be said to you and that’s what makes the nervousness, that anxiety around those conversations. For me [what is needed] would be more knowledge, more training, because I think the more that we've got the more we can talk through that and feel that we’re giving great answers with that. (P27, Female, 52, Nurse, England) However, there was a perception that training providers assumed HCPs would already have these skills. All they deal with is the medical thing like when [vaccination is] needed, why it’s needed.… [Communication is] something you just either know how to do or you don’t, they don’t tackle it in training at all. ( P24, Female, 47, GP, England ) In a few cases, HCPs felt they could communicate effectively due to their professional backgrounds and experience, so training was not necessary for them. Being a nurse for 32 years I'm not sure I needed the “how to communicate something” with a patient. ( P31, Female, 50, Nurse, England ) However, even though HCPs might have built up skills through experience, they reflected that vaccine communication training would still be useful, especially for junior colleagues who did not yet have this experience. Some acknowledged that there was a skills gap in the vaccination workforce when it came to communication. It’s not difficult to train somebody to give an injection. What is difficult is you need somebody with the personality to put people at ease. … I do feel confident having difficult conversations because I’ve been trained to do it. I’m sure there are other vaccinators and some nurses who are not because they’ve not had the privilege of the years’ experience that I’ve got. ( P38, Female, 66, Nurse, England ) Some HCPs felt there were gaps even in existing vaccine-specific communications training, particularly around dealing with patient misconceptions and vaccine misinformation and how to better target communications to different patients. For example, HCPs wished to know how to identify patients’ motivations for vaccine hesitancy. What would help a lot is learning to identify…[the] nuanced side of patients…Once we know who we are talking to, which personality we are talking to, we can use this or that argument [for vaccination]. ( P18, Male, 30, Pharmacist, France ) HCPs also felt that there were gaps in practical skills and tools offered, for example they wanted training that incorporated the difficult conversations they might encounter around patients’ vaccine misconceptions or misinformation so they could learn “ when to stop short of an argument ” ( P24, Female, 47, GP, England ), or have conversation templates to use as “ a roadmap to be able to discuss with people ” (P 12, Male, 67, GP, France ). The Revue du Praticien (in English: Practitioner’s Review) is a generalist medical journal. Discussion The objective of the study was to provide insight into HCPs’ experiences and perspective of vaccine communication and the associated training they had received. In semi-structured interviews with HCPs in England and France, we explored how HCPs approached vaccine conversations with patients, the challenges they had in these conversations, what training they had received to support those conversations, their perception of that training and their unmet training needs. The main approaches to and challenges with vaccine conversations were broadly similar in both countries. HCPs often had conversations with patients to provide vaccine information, which required effective communications skills. However, HCPs were not always supported with sufficient time, informational resources, and skills to confidently navigate difficult conversations with hesitant patients without risking damage to the wider patient-provider relationship that they wished to prioritise. This is consistent with other studies conducted in Ireland, the Netherlands, and Australia, which found that HCPs preferred to avoid conflict to maintain their rapport with patients (Berry et al., 2017 ; Loftus et al., 2021 ; Mollema et al., 2012 ; Ruijs et al., 2012 ). The HCPs we interviewed had received training in delivering vaccinations, with provision differing between countries. HCPs in France mostly recalled vaccine-related training occurring in earlier stages of their career, whereas HCPs in England largely described ongoing training to update their skills and knowledge. In both countries, training mostly covered practical skills and vaccine-specific knowledge, which is in line with existing literature on vaccine training provision (e.g., Kernéis et al., 2017 ; Lanza et al., 2023 ; Public Health England, 2018 ). The informational resources HCPs consulted to increase their vaccine knowledge also targeted the content of vaccine conversations rather than communication style. HCPs who had attended vaccine communication training felt it was useful for dealing with communication challenges. However, the majority of HCPs we interviewed in both countries reported that they had not received such training. This was the case for both nurses and GPs. This may seem surprising since both countries include vaccine communication as a core competency: within the national standard for immunisation training in England and within physicians’ compulsory medical training in France. However, England’s national standard is not mandatory (Public Health England, 2018 ) and while medical students in France are examined on vaccine communication, it does not necessarily mean medical schools have prioritised this aspect of their training (Kernéis et al., 2017 ). Indeed, previous research found that French medical students felt underprepared for questions about vaccination from patients (Kernéis et al., 2017 ). In addition, none of the nurses interviewed in France reported receiving vaccine communication training, whereas in England, several of the nurses we interviewed had received such training. HCPs commonly described accumulating communication skills through their clinical role, or applying communication training (including on motivational interviewing) that they received elsewhere to vaccination contexts. HCPs also picked up skills informally from their colleagues, which suggests that training some HCPs in a team could benefit the whole team. One specific training need highlighted was to provide help finding convincing counter-arguments to patients’ misconceptions. This area was previously identified as needing more research attention (Lanza et al., 2023 ), and we find that there is indeed a gap in training provision here. HCPs would benefit from training that targets why patients hold vaccine misconceptions and what strategies HCPs could use to successfully correct these. This training gap is especially concerning as many misconceptions held by patients stem from misinformation (Betsch et al., 2022 ; Garett & Young, 2021 ; Lewandowsky et al., 2023 ). HCPs in our sample described cases where it was difficult to challenge information from misleading sources, which patients had encountered and believed. In line with past research (Berry et al., 2017 ), HCPs mostly agreed that vaccine communication training would be useful for them and for their colleagues, especially junior HCPs who could benefit from acquiring relevant communication skills earlier in their careers. Thus, it seems promising that HCPs in France mentioned the offer of motivational interviewing training for medical students and interns, though it was not universally available in medical schools across the country nor to nurses. Making this type of communication training specific to vaccination would also be beneficial, as previous work has shown that training medical interns to apply motivational interviewing to vaccination conversations improved their self-efficacy (Garrison et al., 2023a ), which can translate into more frequent vaccine recommendation behaviour among HCPs (Garrison et al., 2023b ). HCPs’ preferences for training delivery reflect a tension between convenience (online training was easily accessible amidst a busy schedule) and enjoyability (face-to-face training was perceived as more engaging and an opportunity to learn through interaction with colleagues). Recent innovations in training delivery—in part accelerated by the need for diverse training media during the COVID-19 pandemic—have provided a range of formats and resources that could be harnessed widely to balance HCPs’ competing needs (Boutros et al., 2023 ). This would be especially helpful for HCPs who have difficulty finding suitable times to attend or travel to organised training. Having a range of online and offline resources for learning as groups or individuals, taught or self-directed, would provide flexibility for HCPs to engage in training as part of their continuing professional development. Crucially, regardless of format, training should be interactive to support HCPs’ learning. Within communication training, specific needs targeting the vaccination context should be addressed. HCPs with more clinical experience or who had attended other forms of communication training expressed confidence with general communication principles, such as listening skills and demonstrating empathy. Some of them described applying these skills successfully in discussions about vaccination, but we do not know how effectively all HCPs can transfer these skills to different contexts. Training in generic communication skills could be more useful for HCPs earlier in their career, when they have not had the opportunity yet to learn from experience. Other specific and complementary skills, such as how to develop convincing responses to correct patient misconceptions about vaccines while preserving the patient-provider relationship, requires greater tailoring of informational resources (Connors et al., 2017 ) and sensitivity to the psychological motivations of the patient (Gagneur, 2020 ; Holford et al., in press). As our interviewees described, HCPs may have a tendency to preserve relationships with their patients, sometimes at the cost of vaccine promotion. Most HCPs, regardless of their clinical expertise, are likely to benefit from developing confidence and skills tailored to handle these types of conversations, and this could increase their self-efficacy and likelihood of recommending vaccines (Garrison et al., 2023b ). Moreover, vaccine-specific communication training may help to combat counterproductive communication habits such as giving information before listening to the patient (Gilkey et al., 2015 ) or dismissing hesitant patients (Dong et al., 2021 ). Incorporating tailored vaccine communication into HCPs’ training, for example to identify the motivations of patients and align communications with those motivations (Holford et al., in press), would also be in line with the WHO’s recommendation to tailor immunisation programmes to understand the perspectives of populations where vaccine coverage is low (Dubé et al., 2018 ). Although our main focus was on HCPs’ communicative capability and training provision around this, many of the HCPs we interviewed also brought up systemic issues around when and where vaccine conversations take place, and how this wider structure of the vaccination environment can impact HCPs’ ability to speak with patients. Communication-specific training will not overcome logistical challenges such as a lack of time or dedicated space for a conversation to happen, nor the growing shortage of HCPs that impacts on the care they can provide to patients (WHO, 2022). It is important to create these conversational opportunities within the healthcare environment. However, this must go hand in hand with preparing HCPs with competencies to engage in effective vaccine communication. Many of the HCPs we interviewed expressed high motivation to speak to patients about vaccines, but they and other colleagues who might be more wary could also increase their motivation to do so with more confidence in their abilities and confidence that patients would receive the conversation well. Limitations Our research offers qualitative insights about how HCPs experience vaccine conversations and training provision around this aspect of their job. However, these in-depth interviews are limited to small samples from each country, so we cannot comment on how prevalent these experiences are among HCPs. Although we recruited a diverse sample in relation to professional roles, regions, genders, and ages, our findings are still limited to a predominantly pro-vaccination sample. The opinions of HCPs who are themselves vaccine hesitant have not been represented as part of this study. Finally, our study only focused on the views of HCPs and did not include patients. We are therefore unable to assess whether HCPs’ perceptions of effective communication match patients’ perceived needs. Conclusion HCPs perceived overcoming vaccine hesitancy through effective conversations as part of their professional role but identified numerous challenges to carrying out their communicative function. HCPs’ training could be improved to teach various specific and complementary skills, such as how to address vaccine misinformation while also communicating in a way that preserves a trustful relationship with patients. Improving such skills may improve HCPs’ motivation to engage in conversations with vaccine-hesitant patients. Training will only be effective when embedded in a supportive system and when its impact is duly evaluated. It should be implemented as part of a systemic approach that provides HCPs with skills, confidence, and logistical support to carry out their vaccine communication roles. Declarations Author notes For the purpose of open access, the author(s) has applied a Creative Commons Attribution (CC BY) licence to any Author Accepted Manuscript version arising from this submission. Ethics approval and consent to participate The research received approval from the School of Psychological Science Research Ethics Committee of the University of Bristol (reference: 119594) and Ethical Committee of Aix-Marseille Université (reference: 2022-10-20-007). The research was conducted in accordance with the principles stated in the Declaration of Helsinki. All participants gave informed consent prior to participating in the study. Consent for publication Not applicable Availability of data and materials Materials used in the study are provided as Supplementary Material to this article. Qualitative interview transcripts may be requested from the corresponding author. Competing interest The authors declare no competing interests. Funding and acknowledgements This project has received funding from the Horizon 2020 Research and Innovation Programme grant 964728 (JITSUVAX). HF acknowledges support from the NIHR Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol. The Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation at University of Bristol is part of the National Institute for Health Research (NIHR) and a partnership between University of Bristol and UK Health Security Agency (UKHSA), in collaboration with the MRC Biostatistics Unit at University of Cambridge and University of the West of England. EB and PV acknowledge support from CAPNET and ANRS-Emerging infectious diseases, and funding and support from the French Ministry of Health and Prevention and the French Ministry of Higher Education, Research and Innovation. Authors’ contributions (using the CRediT system) D.H.: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, and Writing - original draft. E.C.A.: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Validation, and Writing - review & editing. A.B.: Formal analysis and Validation. A.G.: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, and Writing - review & editing. H.F.: Conceptualization, Funding acquisition, Investigation, Methodology, and Writing - review & editing. E.B.: Data curation and Writing - review & editing. V.C.G.: Investigation, Project administration, and Writing - review & editing. P.V.: Conceptualization, Funding acquisition, Methodology, Project administration, Supervision, and Writing - review & editing. S.L.: Conceptualization, Funding acquisition, Project administration, Supervision, and Writing - review & editing. References Berry NJ, Henry A, Danchin M, Trevena LJ, Willaby HW, Leask J. 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J Public Health. 2016;38(4):746–53. https://doi.org/10.1093/pubmed/fdv194 . Additional Declarations No competing interests reported. Supplementary Files SMHCPTrainingNeeds20240201.docx Cite Share Download PDF Status: Published Journal Publication published 20 Jul, 2024 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 29 May, 2024 Reviews received at journal 06 May, 2024 Reviews received at journal 03 May, 2024 Reviewers agreed at journal 22 Apr, 2024 Reviewers agreed at journal 21 Apr, 2024 Reviewers invited by journal 21 Apr, 2024 Editor invited by journal 27 Mar, 2024 Submission checks completed at journal 22 Mar, 2024 Editor assigned by journal 22 Mar, 2024 First submitted to journal 04 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4011945","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":282633818,"identity":"c0ee2715-d77b-4ad8-ba9f-897c0b167a3a","order_by":0,"name":"Dawn Holford","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIie2RMUsDMRTHXxByy/PmHC29rxAQlGJtv0pKIZM3uTocFLLV3clvITc+KaRL5NYDQeoHEO1ScBETuwje1Y4O+cGD5D1+5P8IQCTyHyFfrIR+UgKITQkY7vQ9wv0Koj9kt0Hhu+ZhSu/YP/Wnkq7c6ZpVI8Rk8fJ0UT3387s5EVyPQTpqVTJ3eSaZ04i4Ojkv3BVKyxWBnYF8LFsVScW9YGaJE6F5rzAKJUdJwAlk3R5M1q87BYMy9EpugvK5R2mKHwrzClivMEOdwbLmbSumJuxij4YL54NZrWh6M8OsY/201lpszGiAiWHNR6Um+Xz5sH7fjgepU+3JAr9HqvsjI5FIJHIAX2unW/jCvAhJAAAAAElFTkSuQmCC","orcid":"","institution":"University of Bristol","correspondingAuthor":true,"prefix":"","firstName":"Dawn","middleName":"","lastName":"Holford","suffix":""},{"id":282633819,"identity":"c7e331f1-d318-4100-864d-99387c2bdd1a","order_by":1,"name":"Emma C. Anderson","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Emma","middleName":"C.","lastName":"Anderson","suffix":""},{"id":282633820,"identity":"972c6311-cde8-4bad-953c-26218440b843","order_by":2,"name":"Aishmita Biswas","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Aishmita","middleName":"","lastName":"Biswas","suffix":""},{"id":282633821,"identity":"bdbee250-13e1-4702-9bc5-5cab5fa175c7","order_by":3,"name":"Amanda Garrison","email":"","orcid":"","institution":"Observatoire Regional de la Sante, Provence Alpes Cote d'Azur","correspondingAuthor":false,"prefix":"","firstName":"Amanda","middleName":"","lastName":"Garrison","suffix":""},{"id":282633822,"identity":"4f66094b-c2fc-475c-a6da-d429a57e0124","order_by":4,"name":"Harriet Fisher","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Harriet","middleName":"","lastName":"Fisher","suffix":""},{"id":282633824,"identity":"95673fe3-c5af-435b-a14e-eb83d699c475","order_by":5,"name":"Emeline Brosset","email":"","orcid":"","institution":"Unité des Virus Émergents (UVE: Aix-Marseille Univ, Università di Corsica, IRBA)","correspondingAuthor":false,"prefix":"","firstName":"Emeline","middleName":"","lastName":"Brosset","suffix":""},{"id":282633825,"identity":"9b69cf06-7e99-42de-a282-2fbd0da694ee","order_by":6,"name":"Virginia C. Gould","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Virginia","middleName":"C.","lastName":"Gould","suffix":""},{"id":282633826,"identity":"92d27286-2879-4cb4-92d4-105e1ecd1015","order_by":7,"name":"Pierre Verger","email":"","orcid":"","institution":"Observatoire Regional de la Sante, Provence Alpes Cote d'Azur","correspondingAuthor":false,"prefix":"","firstName":"Pierre","middleName":"","lastName":"Verger","suffix":""},{"id":282633827,"identity":"ea36e0de-e6cd-409e-8622-7b13b4a7ebca","order_by":8,"name":"Stephan Lewandowsky","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Stephan","middleName":"","lastName":"Lewandowsky","suffix":""}],"badges":[],"createdAt":"2024-03-04 14:06:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4011945/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4011945/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12875-024-02509-y","type":"published","date":"2024-07-20T16:13:43+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":61596834,"identity":"27c0ad76-6f25-4314-a0b3-db9af976db31","added_by":"auto","created_at":"2024-08-01 17:30:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":863080,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4011945/v1/f769c7c0-f26b-4515-b752-90e26441307a.pdf"},{"id":53473563,"identity":"7608cddd-239c-401c-a98e-5ea119edd32d","added_by":"auto","created_at":"2024-03-26 12:07:08","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":41762,"visible":true,"origin":"","legend":"","description":"","filename":"SMHCPTrainingNeeds20240201.docx","url":"https://assets-eu.researchsquare.com/files/rs-4011945/v1/f9bb2154c4d251ecf9e09863.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Healthcare professionals’ perceptions of challenges in vaccine communication and training needs: A qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eHealthcare professionals (HCPs) fulfil an important role not just in vaccinating the population, but also in informing patients and caregivers about the benefits and risks of recommended vaccines and addressing their concerns about vaccination. Effective communication is critical to increase patients\u0026rsquo; knowledge and acceptance of vaccine offers. Most people view HCPs as are a major and trusted source of vaccine information (Charron et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Eller et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; O\u0026rsquo;Leary et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), who can offer reassurance and positively impact vaccine decision-making (Leask et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Opel et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Paterson et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). HCPs thus need to be adequately prepared for their communication role and the challenges that may arise as part of it, for example, when speaking with hesitant patients (Donovan \u0026amp; Craig, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Verger et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere are several challenges in mobilising HCPs to proactively recommend vaccination. First, HCPs\u0026rsquo; own attitudes towards vaccines can impact whether they recommend vaccines to patients (Bianco et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Garrison et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2023b\u003c/span\u003e; Yaqub et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Yeung et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Even if HCPs are themselves in favour of vaccination, their personal attitudes may conflict with their desire to enable patient autonomy (Holt et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Loftus et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). HCPs may be themselves uncertain (Verger et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), especially when they need more up-to-date information to reassure themselves of the benefits and costs of newer vaccines (Paterson et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Second, HCPs need relational skills in addition to factual knowledge. These include skills for conveying knowledge in a participatory, non-judgemental manner that displays empathy and maintains the patient-provider relationship (Connors et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), and skills at debunking misinformation that patients may believe (Tafuri et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Training needs to address vaccine communication challenges have previously been identified in primary and secondary care settings (Berry et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Lip et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Lucas Ramanathan et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Sarnquist et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Vorsters et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Williams et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral training interventions to promote tailored, participatory communication in vaccination-related consultations have been developed and reviewed in recent years (Leung et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), for example, Motivational Interviewing (Gagneur, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), the announcement approach (Brewer et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and the Empathetic Refutational Interview (Holford et al., in press). Yet these interventions have not been systematically rolled out in HCP training programmes (Vorsters et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). This could be because communication interventions are not always converted into accessible training or resources for HCPs (Karras et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). It could also be because communication skills are not often prioritised in medical training, except on very sensitive aspects of medicine such as announcing a diagnosis of cancer (Rotthoff et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Indeed, vaccination training has typically focused on vaccine knowledge and practical skills required to deliver vaccines (Sherris et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2006\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn addition, communications training tended to target the informational content of the communication (e.g., risks and benefits of vaccines that one should tell the patient), rather than the style (e.g., using empathetic language and tone to deliver that information; Lanza et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Public Health England, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). There is a research gap regarding HCPs\u0026rsquo; training needs around identifying and addressing patients\u0026rsquo; main barriers to vaccination (Lanza et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), which this qualitative study addresses. Our objective was to explore HCPs\u0026rsquo; experiences and perceptions of the vaccine communication challenges they faced, what training they had received to prepare them for these challenges, and what training needs remained.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eThe research received approval from the ethics committees of the authors\u0026rsquo; institutions [blinded]. The research was conducted in accordance with the ethical principles under the Declaration of Helsinki. All participants gave informed consent prior to participation.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eWe focused on HCPs in England and France who hold vaccination roles (i.e., including at least one of the following tasks: recommending, prescribing, discussing, or delivering vaccination) to explore training provision and experiences under two different health systems. In England, vaccination involves a range of professionals (including, for example, nurses, midwives, pharmacists) in prescription, recommendation, discussion, and delivery of vaccination (UKHSA, 2020). In France, vaccination has been mainly carried out by General Practitioners (GPs), but in the last decade, the authorities gradually extended the role of prescribing and delivering vaccination to other health professionals who have undertaken advanced studies (e.g., nurses, pharmacists, midwives; L\u0026eacute;gifrance, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Verger et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn England, the national vaccine training syllabus recommends communicating with patients, but this is only taken as guidance and need not be offered in practice (Public Health England, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). In France, vaccine communication is a compulsory aspect of physicians\u0026rsquo; medical training and clinical examinations, but how the training is delivered is left up to each medical school (Kern\u0026eacute;is et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Nurses in France undergo compulsory training that includes 4\u0026ndash;5 hours of vaccination theory during three years of medical studies, with practical training on recommending and administering vaccines completed during medical placements (Bourquin, 2021).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment of participants\u003c/h2\u003e \u003cp\u003eHCPs whose roles involved vaccination (i.e., at least one of the following: prescribing, recommending, discussing, and/or delivering vaccination) were invited to take part, with recruitment aiming for a range of ages, genders, professions, and settings (in England, different geographical regions; in France, rural or urban settings). Participants were offered compensation for their time (\u0026pound;20 shopping vouchers in England; \u0026euro;50 in France).\u003c/p\u003e \u003cp\u003eIn England, participants were recruited via email from a mailing list of 104 previous participants (response rate\u0026thinsp;=\u0026thinsp;22%) who had agreed to be contacted for interviews after completing an earlier study on vaccination attitudes and behaviours (Garrison et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2023b\u003c/span\u003e). In France, participants were recruited by contacting General Practitioners (GPs) through publicly available list-serves, asking participants to share invitations with colleagues, and requesting the Regional Union of Healthcare Professionals for Nurses (UPRS Infirmi\u0026egrave;res) to send out invitations. Seventy invitations were sent to HCPs in southeastern France (response rate\u0026thinsp;=\u0026thinsp;25%). Recruitment in both countries continued until the researchers agreed that an appropriate range of healthcare professionals were represented and reasonable data saturation to meet the main research objectives had been achieved (Shaw et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eConsent and interview procedures\u003c/h2\u003e \u003cp\u003ePrior to the interview, participants were sent an information sheet and consent form electronically. Participants returned the signed consent form electronically or verbal consent was obtained during the interview.\u003c/p\u003e \u003cp\u003eAll interviews were held over video- or tele-conferencing and audio-recorded. Semi-structured interviews were conducted in English and French by experienced qualitative researchers with the appropriate language skills ([blinded]). Interviews were planned to take between 30\u0026ndash;60 minutes, following a topic guide that specified key question areas and prompts for interviewers (see Supplemental Material).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eAll interview recordings were transcribed verbatim. French transcripts were translated into English by an English-speaking researcher fluent in French ([blinded]) with the assistance of two native French speakers ([blinded]) where necessary. We followed familiarisation steps in thematic analysis protocols (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2006\u003c/span\u003e): at least one researcher from each team ([blinded]) read all transcripts from their country to understand the data and identify potential themes in the transcripts. Based on this preliminary analysis, the research team created a framework to systematically analyse the transcripts with respect to four domains relevant to understanding HCPs\u0026rsquo; vaccine communication training needs and provision (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, column 1). Two researchers ([blinded]) then read and coded all transcripts with regards to the initial framework, with additional themes identified and added after discussion. Coding was completed using NVivo 13 (Lumivero, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). To ensure consistency in coding, the two researchers first independently coded the same four transcripts (10%) and discussed them to reach consensus. Two rounds of independent coding and review were completed, first to reach consensus on the four domains, and then on the themes identified within the four domains. All coding discrepancies were resolved through discussion and the framework was updated iteratively between rounds of discussion to improve consistency of interpretation. Thereafter, the remainder of transcripts were coded individually by [blinded] and [blinded], who met regularly throughout the coding process to discuss any uncertainties.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes from four domains related to HCPs\u0026rsquo; vaccine communication and training needs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e1. HCPs\u0026rsquo; approach to vaccine conversations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA. HCPs\u0026rsquo; perception of their communication role.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB. Informational content of the conversation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC. Communication styles HCPs use in vaccine conversations.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e*D. HCPs\u0026rsquo; perception of the experience of vaccine-related conversations with patients.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e2. Challenges HCPs face in vaccine communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA. Difficulties in addressing misconceptions/misinformation and/or changing patients\u0026rsquo; minds.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB. Lack of information, including lack of up-to-date information to give patients.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC. Needing time and space to have the conversations.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD. How communication skills can help in difficult conversations.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eE. Needing to maintain relationships with patients and avoid conflict.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e3. Vaccination-related training and learning among HCPs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA. Existing training coverage (including \u003cem\u003ehow\u003c/em\u003e and \u003cem\u003ewhat\u003c/em\u003e).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB. Experiential learning (from peers and work experience).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC. Official information sources consulted.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e*D. Perception of informational resources.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e4. HCPs\u0026rsquo; perception of existing communications training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA. Perceptions about content of existing communications training.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB. Perceptions of different training formats (e.g., face to face, online).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC. Perceived relevance of existing communications training.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eD. Gaps in training (including if this type of training is not offered).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Indicates themes added to the initial analysis framework after discussion during the coding process.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBetween July to November 2022, we interviewed 41 HCPs from England (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;23) and France (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18). Socio-demographic characteristics can be found in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics of interview participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eNumber (%)\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharacteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFrance (\u003c/b\u003e\u003cb\u003en\u003c/b\u003e\u0026thinsp;\u003cb\u003e=\u0026thinsp;18)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eEngland (\u003c/b\u003e\u003cb\u003en\u003c/b\u003e\u0026thinsp;\u003cb\u003e=\u0026thinsp;23)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eTotal (\u003c/b\u003e\u003cb\u003en\u003c/b\u003e\u0026thinsp;\u003cb\u003e=\u0026thinsp;41)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral practitioner (GP)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (37%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (58%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (63%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (37%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (20%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;49 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (34%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;50 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (46%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion (England)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEast of England\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouth East\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLondon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWest Midlands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouth West\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion (France)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote.\u003c/em\u003e *Other\u0026thinsp;=\u0026thinsp;pharmacist (France) and community health worker (England)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the final themes identified through thematic analysis of the transcripts. The results presented below summarise the key issues that relate to HCPs\u0026rsquo; vaccine communication with patients and their unmet training needs, organised by the four domains and their main themes. We illustrate each theme with quotations that concisely represent typical responses of interviewees from both countries.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eHCPs\u0026rsquo; approach to vaccine conversations\u003c/h2\u003e \u003cp\u003e \u003cb\u003ePerception of communication role.\u003c/b\u003e All HCPs recognised vaccine communication was part of their role. Many felt that they needed to provide information for patients to make their own informed decisions on vaccination.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eBefore taking a position or not, we need to first simply inform that there is this or that vaccine, that certain ones are mandatory, some are recommended, that some are reimbursed, some are not\u0026hellip;and then according to the reception of this information, [we have] an advising role.\u003c/em\u003e (\u003cem\u003eP04, Male, 41, GP, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMost HCPs discussed communication in the context of recommending vaccines to patients and answering their questions about vaccines, but several also highlighted that they discussed vaccination outside of their patient-facing roles, for example with family, friends, and colleagues:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI had members of my family even who were against it\u0026hellip;but they asked me often about what I thought and to explain [vaccination] to them.\u003c/em\u003e (\u003cem\u003eP16, Female, 26, GP, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eInformational content of conversation.\u003c/b\u003e HCPs often described using scientific and medical information to inform and correct misconceptions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI tried to stay with arguments that have a bit of scientific proof...even looking up in front of them studies that show the decrease in incidence of the disease since vaccination began.\u003c/em\u003e (\u003cem\u003eP15, Male, 35, GP, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHCPs would also explain to patients why vaccination was beneficial from an individual as well as collective standpoint.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI will talk about the benefits of having the vaccinations to protect baby from infections, pros and cons and that sort of thing with new mums.\u003c/em\u003e (\u003cem\u003eP28, Female, 42, GP, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome HCPs also mentioned that they would share personal experiences and anecdotes when they felt this information was relevant to encourage their patient to be vaccinated.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI tell them that I was sick. That I was almost on a ventilator, because they see me as someone who is strong\u0026hellip;a solid guy, a doctor. Someone who isn\u0026rsquo;t fragile.\u003c/em\u003e (\u003cem\u003eP12, Male, 67, GP, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eCommunication style.\u003c/b\u003e Many HCPs were comfortable with initiating conversations about vaccination and encouraging their patients to be vaccinated.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI try to promote actively vaccinations to everyone, every patient, children and adults and I use that in every contact that I have in the surgery.\u003c/em\u003e (\u003cem\u003eP20, Male, 46, GP, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, some HCPs felt uncomfortable if the patient was hesitant and would refrain from pursuing the subject of vaccines further.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI didn\u0026rsquo;t respond [to the patients\u0026rsquo; concern], in fact. I knew that the communication was complicated, and so if they asked me questions, I responded, but after, I left them to their beliefs.\u003c/em\u003e (\u003cem\u003eP11, Female, 41, Nurse, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhen speaking with hesitant patients, most HCPs highlighted the need to respect patient autonomy in their vaccination decision. For some, this meant remaining neutral at the beginning of the conversation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI try not to push them in either direction, I just give them the information and just say, if you would like to have these vaccines then just make an appointment. (P22, Female, 33, GP, England)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFor others, respecting autonomy meant letting the patient make the ultimate decision but still trying to support them with that decision.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eEven if for me, [although] I find [it] a shame to not vaccinate\u0026hellip;from the moment that [patients] are aware of the risks\u0026hellip;we listen and try to help them with their choice while respecting their wish to not get vaccinated.\u003c/em\u003e (\u003cem\u003eP08, Male, 42, Nurse, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome HCPs from England reported encouraging patients to look up reliable information for themselves. This approach was not mentioned by HCPs in France, although they discussed similar goals of providing reassurance, information, and explanations about vaccines.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eMy approach is to reassure them, show them the information we have got and with pregnant women I\u0026rsquo;ve found a link to a podcast which I thought they might like to follow up on.\u003c/em\u003e (\u003cem\u003eP19, Male, 62, Nurse, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome HCPs described communication techniques they had been trained to use, for example, counselling skills, how to listen, ways to tailor information, and the use of analogies. The purpose of these techniques was to reflect empathy and openness towards their patients.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt\u0026rsquo;s about listening and about hearing what that objection is and then to try and relate it to the current day.\u003c/em\u003e (\u003cem\u003eP36, Female, 64, Nurse, England\u003c/em\u003e)\u003c/p\u003e \u003cp\u003e \u003cb\u003ePerception of vaccine conversation experience.\u003c/b\u003e HCPs described some vaccine conversations as \u0026ldquo;difficult\u0026rdquo; and \u0026ldquo;unpleasant\u0026rdquo;, in which they faced challenges in vaccine communication detailed in the next section. In contrast, other vaccine conversations were described as \u0026ldquo;easy\u0026rdquo; and \u0026ldquo;comfortable\u0026rdquo;. In these conversations, patients listened, HCPs had a good relationship with the patient, and HCPs had confidence in their own communication skills and felt prepared for the conversation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eYou think beforehand [of] all the scenarios of what you might be asked. That\u0026rsquo;s how\u0026hellip;in the conversation I didn\u0026rsquo;t feel challenged. I think [the patient] was quite happy to receive [the information].\u003c/em\u003e (\u003cem\u003eP27, Female, 52, Nurse, England)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eChallenges in vaccine communication\u003c/h2\u003e \u003cp\u003e \u003cb\u003eDifficulties in addressing patients\u0026rsquo; misconceptions and fixed beliefs.\u003c/b\u003e HCPs described various challenges they faced when patients displayed resistance to vaccines. This was generally in response to the HCP\u0026rsquo;s recommendations, but a few HCPs had also faced challenging patients who arrived for their vaccination upset about vaccination mandates (e.g., for travel or professional purposes).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThere are a lot of people who did [vaccination] really for professional reasons. It is [these] people who would come and be angry.\u003c/em\u003e (\u003cem\u003eP10\u003c/em\u003e, \u003cem\u003eFemale, 56, Nurse, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHCPs described some of the doubts and concerns of their patients as legitimate, but others they considered irrational. For example, HCPs appreciated their patients\u0026rsquo; logic for declining vaccination.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThose [patients] that believe that the data is not sufficiently robust enough and don\u0026rsquo;t wish to be part of a large experiment until they\u0026rsquo;ve got longer term data\u0026hellip;we\u0026rsquo;ve peddled that line ourselves with new drugs and new technologies all the time. So, although it\u0026rsquo;s not a position that I think is the most sensible, it is a logical position.\u003c/em\u003e (\u003cem\u003eP23, Male, 52, GP, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn other instances, HCPs questioned the reasoning that some patients used to reject vaccination.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e[The patients\u0026rsquo;] reasons were fear of needles and they were covered in tattoos\u0026hellip;so there\u0026rsquo;s some warped perceptions of what they\u0026rsquo;re prepared to put themselves through or not.\u003c/em\u003e (\u003cem\u003eP41, Female, 57, Nurse, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHCPs were able to detail some misconceptions patients had about vaccines, which many HCPs identified as coming from unreliable information sources such as social media.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThe paradox is that they have more confidence in Facebook groups than in studies.\u003c/em\u003e (\u003cem\u003eP01, Male, 25, GP, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne HCP reflected that even credible information sources could be misinterpreted by people without the right expertise.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWithout the real expert understanding and knowledge and everything that happened behind that, in some ways [the sources] are more dangerous than they are informative at times. \u0026hellip; [The patient] read a BMJ [British Medical Journal] paper\u0026hellip;She basically found what we\u0026rsquo;d call credible evidence, but then came to her own conclusion about it.\u003c/em\u003e (\u003cem\u003eP36, Female, 64, Nurse, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe most difficult experiences cited included patients with religious objections and conspiratorial beliefs. In extreme cases patients became aggressive, accused HCPs of being part of the conspiracy and of wanting to harm children with vaccinations.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThat is also the problem, that they think so much about the conspiracy that you give an argument in favour of vaccination and they envelop you in the conspiracy. (P01, Male, 25, GP, France)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMany HCPs recognised that hesitant patients\u0026rsquo; mindsets could be difficult to change. Some HCPs found this resistance to change challenging and were discouraged from continuing vaccine conversations with these patients:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eFrom the moment I understand that no matter what my response [is], it will not change their way of thinking...I let it go.\u003c/em\u003e (\u003cem\u003eP02, Female, 52, GP, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOthers displayed confidence and willingness to engage with patients with such mindsets nonetheless, reflecting that the conversation might still do some good.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThe people of that cohort are usually of a fixed mindset and it\u0026rsquo;s quite difficult to shift that, and we hope that having that conversation may make them shift it.\u003c/em\u003e (\u003cem\u003eP21, Male, 33, GP, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eLack of information to give patients.\u003c/b\u003e HCPs most commonly discussed lack of knowledge and uncertainties in how to respond to concerns in the context of COVID-19 vaccination programmes. Particularly at the start of the vaccine roll-out, HCPs struggled with the lack of official information resources to support evidence-based conversations with patients and delays in receiving official government advice. HCPs had encountered conflicting information that contributed to their uncertainties in responding to patients and felt that reliable information was often obscured amidst large amounts of false information on the Internet.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWhat made me uncomfortable was also that I didn\u0026rsquo;t have enough information\u0026hellip; [patients] would say \u0026ldquo;okay, tell me what are the side effects, there are women who aren\u0026rsquo;t able to have children any more\u0026rdquo; and I was uncomfortable because I didn\u0026rsquo;t really know how to respond\u003c/em\u003e. \u003cem\u003e(P09, Female, 57, Nurse, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTwo HCPs from France also had doubts about the necessity of COVID-19 vaccine for some of their patients.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eAs a citizen, I do not really agree with vaccinating the youngest [against COVID-19], for example.\u003c/em\u003e (\u003cem\u003eP14, Male, 52, Nurse, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA more general information deficit for some HCPs was the lack of convincing counterarguments for patients\u0026rsquo; misconceptions, particularly when these concerns were motivated by misinformation or conspiracist beliefs and patients did not believe the factual information the HCP had provided.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eShe was saying how she was reading conspiracy theories online. I didn\u0026rsquo;t really know how to address that one, but I was just trying to say to her, \u0026ldquo;It is effective, it does go through all these clinical trials, so it is very much safe.\u0026rdquo;\u003c/em\u003e (\u003cem\u003eP32, Female, 29, Nurse, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eNeeding time and space for vaccine conversations.\u003c/b\u003e Some HCPs highlighted the substantial time it took to respond to patients\u0026rsquo; doubts and concerns about vaccines. This was especially challenging for HCPs working in primary care. Often they reported having short consultations where the principal focus was not vaccination, leaving limited time to dispel vaccine misconceptions or engage in a convincing discussion with hesitant patients.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI don\u0026rsquo;t have the time built into my consultations for it\u0026hellip;if they\u0026rsquo;re coming for something else, to then add that on to the consultation that\u0026rsquo;s another 10 minutes and I\u0026rsquo;ve got another patient waiting so it\u0026rsquo;s quite tricky.\u003c/em\u003e (\u003cem\u003eP28, Female, 42, GP, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome HCPs in England shared experiences where their organisations had implemented effective solutions to make time for vaccine conversations. These generally involved creating opportunities for patients to speak with a medical professional, for example:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026hellip;\u003cem\u003ehaving chats with patients rather than bringing them in on the fast-paced in/out clinics\u0026hellip;being able to have time with patients provides a more positive reinforcement and outcome for the patients and their experience with having the vaccine.\u003c/em\u003e (\u003cem\u003eP33, Female, 27, Nurse, England\u003c/em\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eHow communication skills help with difficult conversations.\u003c/b\u003e HCPs shared some of their strategies to try and reach positive outcomes when they engaged in challenging vaccine conversations. A variety of communication skills were described, for example positive non-verbal communication and active listening to clarify the patients\u0026rsquo; concern and enable the HCP to adapt their response to the patients\u0026rsquo; needs.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eIt\u0026rsquo;s about that paraphrasing\u0026hellip;so that you understand what the actual concern is before you answer them, because otherwise you\u0026rsquo;re just assuming what their anxiety or fear is about rather than finding out.\u003c/em\u003e (\u003cem\u003eP29, Female, 56, Nurse, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMany HCPs would remind patients of their autonomy and tell the patient they respected the patient\u0026rsquo;s choice. In some cases, this meant the HCP did not pursue the conversation any further, or would tone down their vaccine recommendations for vaccine hesitant patients whom they thought would react poorly to strong recommendations.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI know through experience that that doesn\u0026rsquo;t serve any good to take a strong position that could seem condescending to people who, they themselves are against vaccines.\u003c/em\u003e (\u003cem\u003eP04, Male, 41, GP, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe ability to adapt the conversation to the patient was also described as particularly important when speaking to patients who were ambivalent with regards to accepting vaccination.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThere are things to put in place and things to say and things to not say\u0026hellip;to adapt the discussion\u0026hellip;to explain to those who are \u0026ldquo;convincible\u0026rdquo;\u0026hellip;I think there are people for which there are arguments and things can be done to bring them onto the side of vaccination.\u003c/em\u003e (\u003cem\u003eP15, Male, 35, GP, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHCPs agreed that despite their importance, developing effective communications skills was challenging. Some HCPs mentioned professional experiences and training that helped develop these skills, but they recognised that not all their colleagues had the skills to communicate well.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eSome vaccinators can\u0026rsquo;t do that [communicate well] so I don\u0026rsquo;t think they\u0026rsquo;ve given the best experience [to patients].\u003c/em\u003e (\u003cem\u003eP38, Female, 66, Nurse, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eA need to maintain patient-provider relationships.\u003c/b\u003e Many HCPs highlighted trust as an important component that facilitated vaccine conversations with patients by increasing patients\u0026rsquo; receptivity to the HCP\u0026rsquo;s vaccine recommendations. Providing continuing care and getting to know patients on a personal level was one way to develop this trusted relationship.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI think it helps if you have got a relationship with that patient already. If they know you and trust you, if you say things to them, they\u0026rsquo;re much more likely to hear them.\u003c/em\u003e (\u003cem\u003eP39, Female, 51, GP, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome HCPs described how communication skills helped to build trust, for example by ensuring the environment was conducive for the conversations.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIt is how you use your body language, how you talk to them and it is just general interaction. \u0026hellip; We have got an area where we can actually take them [we talk] one to one and not in a public space. I\u0026rsquo;m coming around to chat to them face to face, to break down any barriers because when you\u0026rsquo;ve been sitting behind a table it looks like you are superior and you are telling them what to do.\u003c/em\u003e (\u003cem\u003eP19, Male, 62, Nurse, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlthough HCPs believed that trust was helpful for effective vaccine communication, it could in some circumstances also be counterproductive.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIt is good because they trust us, and so that helps to speak openly, but sometimes what is bad is that because they treat us like family, sometimes they don\u0026rsquo;t listen to us.\u003c/em\u003e (\u003cem\u003eP06, Male, 37, Nurse, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHCPs\u0026rsquo; prioritisation of maintaining a trusted relationship could also lead them to avoid giving certain information or back away from discussing vaccines if they sensed patients were unreceptive or that the conversation would take too much time. HCPs mentioned not wanting to get into arguments or damage existing relationships by enforcing their own beliefs about vaccines, particularly as vaccination was only one aspect of their care relationship with their patients.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eYou can only try so far and then you can tell if you\u0026rsquo;re starting to alienate them and you\u0026rsquo;re affecting your relationship with them so I think you just have to respect their decision\u0026hellip;you do have to back off.\u003c/em\u003e (\u003cem\u003eP30, Female, 65, Nurse, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eVaccination-related training and learning\u003c/h2\u003e \u003cp\u003e \u003cb\u003eExisting training coverage.\u003c/b\u003e All but one of the HCPs interviewed described receiving practical training to administer vaccinations. This focused on procedures and techniques of vaccine delivery, including obtaining informed consent, in addition to information about how vaccination works, the contents of different vaccines, and their country\u0026rsquo;s vaccination schedule. Many HCPs in France described vaccination-related modules they had completed during their initial professional training, while many HCPs in England mentioned vaccine-specific training that was available before taking up vaccination roles. Most training was on vaccine theory and practical aspects; only a few HCPs mentioned their courses tried to address discussions with vaccine-hesitant patients.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIt was just theory when we talked about [vaccines], when we were in school. That was several years ago and now, [there is] nothing in particular for vaccination.\u003c/em\u003e (\u003cem\u003eP17, Female, 47, Nurse, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome HCPs described training they had received around communicating with patients, mostly in the context of their other professional roles and not specific to vaccines.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI actually did the Diploma in Child Health\u0026hellip;so I\u0026rsquo;ve done that sort of communication skills and the knowledge that you need during [that] training.\u003c/em\u003e (\u003cem\u003eP23, Male, 52, GP, England\u003c/em\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e In France, a few HCPs highlighted motivational interviewing training that was available at an early career stage (though it was not only targeted at vaccination).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e During [my] internship, I followed a training about motivational interviewing\u0026hellip;that can also be used, for example, for tobacco. (P03, Female, 28, GP, France)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eExperiential learning.\u003c/b\u003e HCPs mentioned that learning took place without direct instruction during their professional training. Most of these HCPs had been in the profession for decades and they felt the many patients they had spoken to over the years helped them to gain transferable expertise with patient conversations.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI was a surgical nurse for quite a number of years\u0026hellip;we would have to impart bad news\u0026hellip;so actually you learn those communication skills.\u003c/em\u003e (\u003cem\u003eP31, Female, 50, Nurse, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eProfessional peers were also a source of experiential learning for HCPs, as HCPs picked up skills from watching their supervisors and colleagues.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI think the team in the whole are quite skilled at communicating\u0026hellip;and then the new staff coming through hear those conversations all the time so they learn from it.\u003c/em\u003e (\u003cem\u003eP37, Female, 51, GP, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHCPs also described useful opportunities for discussing best practice with peers, for example in forums with other HCPs. Pharmacists were highlighted as good colleagues to learn from as they had good knowledge of vaccines and, specifically in France, often spoke to patients.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe were in contact with pharmacists because they were our intermediaries [with patients]\u0026hellip;the pharmacist would say, \u0026ldquo;oh well if you have all of these doses do it this way.\u0026rdquo; (P07, Male, 57, Nurse, France)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eOfficial sources of information consulted.\u003c/b\u003e HCPs tended to seek out information on vaccines for their own knowledge and to use in consultation with patients, as a form of self-directed learning. Most explicitly mentioned using \u0026ldquo;reliable information\u0026rdquo; coming from national public health organisations (e.g., in England, the National Health Service \u0026ldquo;NHS\u0026rdquo;; in France, the national health insurance fund website \u0026ldquo;AMELI\u0026rdquo;, regional health agency \u0026ldquo;ARS\u0026rdquo;, and expert health authority that recommends vaccines \u0026ldquo;HAS\u0026rdquo;).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe made it very clear that we would only access information from two places [the government and the NHS], and if there was any wealth of information elsewhere, we would just simply acknowledge it but we wouldn\u0026rsquo;t use it ourselves in sharing to others.\u0026rdquo;\u003c/em\u003e (\u003cem\u003eP21, Male, 33, GP, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn England, many HCPs explicitly cited the Green Book (the official government resource for vaccination procedures in the UK), with most describing it as \u0026ldquo;their bible\u0026rdquo;. Some HCPs also used the Internet to search for specific information; others discussed information they got from news media, professional bodies (e.g., French Society of Infectious Diseases), independent organisations (e.g., Oxford Vaccine Group), scientific publications, and pharmaceutical companies.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePerception of informational resources.\u003c/b\u003e HCPs had differing views on the usefulness of information they had access to about vaccination. A few felt they were too busy to look through the information and that it would be helpful if it could be summarised.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe receive the Revue du Praticien\u003c/em\u003e \u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e1\u003c/a\u003e \u003cem\u003eat the practice but I admit I absolutely do not have the time to look into it.\u003c/em\u003e (\u003cem\u003eP02, Female, 52, GP, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe Green Book (the resource for UK vaccination) was specifically highlighted as a useful resource because it was \u0026ldquo;\u003cem\u003eincredibly well organised and contains the right amount of actual research and also stating the facts simply but not too much complex detail that it\u0026rsquo;s not easy to understand\u003c/em\u003e\u0026rdquo; (\u003cem\u003eP35, Female, 25, Nurse, England\u003c/em\u003e) and provided \u0026ldquo;\u003cem\u003ea framework for knowing what I need to talk to [patients] about\u003c/em\u003e\u0026rdquo; (\u003cem\u003eP23, Male, 52, GP, England\u003c/em\u003e).\u003c/p\u003e \u003cp\u003eWith regards to information resources to share with patients, HCPs felt they lacked lay information that they could give directly to patients. Some HCPs felt that the official vaccine information leaflets that were provided for patients were unsuitable.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI think the leaflets that are there trying to explain to the patients in layman\u0026rsquo;s language about the vaccine\u0026hellip;I\u0026rsquo;ve never liked them \u0026hellip; I think it\u0026rsquo;s a bit too much sometimes\u0026hellip;it is a lot of information\u0026mdash;I\u0026rsquo;m not sure who is going to read that. I think it can be a bit more simple probably.\u003c/em\u003e (\u003cem\u003eP20, Male, 46, GP, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, others mentioned that they could find appropriate information for their patients on official websites such as that of the NHS.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e[The information was] broken down into easy to digest chunks...I think it presents it in quite a logical manner without there being too much information overload.\u003c/em\u003e (\u003cem\u003eP22, Female, 33, GP, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eHCPs\u0026rsquo; perception of vaccine communication training\u003c/h2\u003e \u003cp\u003e \u003cb\u003eContent of existing communications training.\u003c/b\u003e Some HCPs gave details of vaccine communication training they had either attended or knew about from colleagues. For example, one described a COVID-19 vaccine training module where \u0026ldquo;\u003cem\u003ethere was a brief aspect to the module where it goes on to say when people are not sure about having the vaccine, these are the things that you can say to encourage uptake\u003c/em\u003e\u0026rdquo; (\u003cem\u003eP21, Male, 33, GP, England\u003c/em\u003e). Another mentioned that motivational interviewing for vaccine conversations was \u0026ldquo;\u003cem\u003esomething that is new that is now proposed as a training module when we are interns\u003c/em\u003e\u0026rdquo; (\u003cem\u003eP41, Male, 41, GP, France\u003c/em\u003e)\u0026mdash;although it should be noted that such vaccine-specific communications training for medical interns is still not compulsory in the French system.\u003c/p\u003e \u003cp\u003eMore commonly, HCPs described communication training they had received as students or in the context of other professional roles rather than as preparation for their vaccination duties. This training covered skills that were transferable such as how to involve patients in their own care, how to convey bad news to patients, and how to navigate tricky conversations with people.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe had some sessions of practical situations with complicated patients. But\u0026hellip;it was about other subjects, like about antibiotics for example, or announcing a serious disease.\u003c/em\u003e (\u003cem\u003eP16, Female, 26, GP, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHCPs described the use of role plays and practical situations in their general communication training to simulate patient scenarios, direct instructions about what facts to give patients, and sessions where trainees had discussions and sharing of experiences.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFormats of existing training.\u003c/b\u003e HCPs described a variety of training formats they had experienced, including webinars, seminars and conferences, online modules, and workshops. HCPs acknowledged that different training formats had their merits and drawbacks. Online training was generally seen as more accessible, allowing HCPs to schedule it into their day without needing to travel to a training location. One advantage of online training (specifically, \u0026ldquo;e-learning\u0026rdquo;) was its ability to be self-directed so individuals did not need to be present at a fixed time and could go through materials at their own pace or repeat learning content. In some cases, it could also be designed to be interactive.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI quite like it when it's smaller blocks, and when it has lots of pictures. I like lots of videos and animations and things like that\u0026hellip;I learn much better that way.\u0026hellip;I quite like that after each section you are tested as well on it, because that helps to cement it in place.\u003c/em\u003e (\u003cem\u003eP40, Female, 51, Nurse, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, when this type of training was limited to an online presentation, some HCPs questioned its utility.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eHalf the time it's going in one ear and out the other, and by the time [one goes] back to work it's like, \u0026ldquo;Well, what did I learn?\u0026rdquo;\u003c/em\u003e (\u003cem\u003eP33, Female, 27, Community health worker, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Although face-to-face training presented logistical challenges, many HCPs felt that it was more enjoyable and provided more opportunities for interaction and practice through various exercises.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI think it was good to have a training with role playing and the trainers who explained things well, it was better than learning in books.\u003c/em\u003e (\u003cem\u003eP05, Female, 27, GP, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eRelevance of existing communications training.\u003c/b\u003e Most HCPs who had experienced training related to vaccine communication felt that it was relevant and helpful to their roles and they had subsequently put it into practice.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI think educating yourself, learning and updating yourself with the latest information, that really gives you the confidence, because you can then impart that information to the patients.\u003c/em\u003e (\u003cem\u003eP40, Female, 51, Nurse, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome HCPs felt that it was more useful to target the communication style (e.g., how to approach patients) and include practical exercises, as opposed to just providing informational content (e.g., what to say).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIt's always been, \u0026ldquo;This is the spiel I give them but the best thing you can do is have a read of the leaflet, and then figure out on your own.\u0026rdquo; When you hear things like that you think, I don't quite like the feel of that.\u003c/em\u003e (\u003cem\u003eP33, Female, 43, Nurse, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHCPs in France who had undergone Motivational Interviewing training (for patient communication in general) described how they had put that training into practice.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI think that [it] helps me sometimes when I don\u0026rsquo;t have arguments or I feel that the patient is a bit upset, I try to use the basics of the motivational interview to get back on track. And that works pretty well.\u003c/em\u003e (\u003cem\u003eP05, Female, 27, GP, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHCPs who had described communications training in the context of other roles also felt that training had relevance to their vaccination conversations.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eYou want to be able to have an engaging conversation and make sure people walk away from it feeling positive. So, having done that training before about managing challenging conversations has definitely been helpful in my role as a vaccinator.\u003c/em\u003e (\u003cem\u003eP32, Female, 29, Nurse, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eGaps in vaccine communication training.\u003c/b\u003e The main training gap identified by the majority of HCPs was that vaccine communication was often not covered.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eNever in our training as vaccinators did they say, \u0026ldquo;This is how you address this, if a person says this,\u0026rdquo; so [vaccine communication] was just something that I was just a bit unsure about.\u003c/em\u003e (\u003cem\u003eP32, Female, 29, Nurse, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHCPs felt that their existing training focused on vaccine knowledge but \u0026ldquo;\u003cem\u003ethey don\u0026rsquo;t tell you how to sit and talk to a patient\u003c/em\u003e\u0026rdquo; (\u003cem\u003eP26, Male, 65, Nurse, England\u003c/em\u003e). HCPs expressed the desire to have such training, so they could learn new things, refresh their knowledge, and increase their confidence.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eYou never know what's going to be said to you and that\u0026rsquo;s what makes the nervousness, that anxiety around those conversations. For me [what is needed] would be more knowledge, more training, because I think the more that we've got the more we can talk through that and feel that we\u0026rsquo;re giving great answers with that. (P27, Female, 52, Nurse, England)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, there was a perception that training providers assumed HCPs would already have these skills.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eAll they deal with is the medical thing like when [vaccination is] needed, why it\u0026rsquo;s needed.\u0026hellip; [Communication is] something you just either know how to do or you don\u0026rsquo;t, they don\u0026rsquo;t tackle it in training at all.\u003c/em\u003e (\u003cem\u003eP24, Female, 47, GP, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn a few cases, HCPs felt they could communicate effectively due to their professional backgrounds and experience, so training was not necessary for them.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eBeing a nurse for 32 years I'm not sure I needed the \u0026ldquo;how to communicate something\u0026rdquo; with a patient.\u003c/em\u003e (\u003cem\u003eP31, Female, 50, Nurse, England\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, even though HCPs might have built up skills through experience, they reflected that vaccine communication training would still be useful, especially for junior colleagues who did not yet have this experience. Some acknowledged that there was a skills gap in the vaccination workforce when it came to communication.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt\u0026rsquo;s not difficult to train somebody to give an injection. What is difficult is you need\u003c/em\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003esomebody with the personality to put people at ease. \u0026hellip; I do feel confident having difficult conversations because I\u0026rsquo;ve been trained to do it. I\u0026rsquo;m sure there are other vaccinators and some nurses who are not because they\u0026rsquo;ve not had the privilege of the years\u0026rsquo; experience that I\u0026rsquo;ve got.\u003c/em\u003e (\u003cem\u003eP38, Female, 66, Nurse, England\u003c/em\u003e)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eSome HCPs felt there were gaps even in existing vaccine-specific communications training, particularly around dealing with patient misconceptions and vaccine misinformation and how to better target communications to different patients. For example, HCPs wished to know how to identify patients\u0026rsquo; motivations for vaccine hesitancy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWhat would help a lot is learning to identify\u0026hellip;[the] nuanced side of patients\u0026hellip;Once we know who we are talking to, which personality we are talking to, we can use this or that argument [for vaccination].\u003c/em\u003e (\u003cem\u003eP18, Male, 30, Pharmacist, France\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHCPs also felt that there were gaps in practical skills and tools offered, for example they wanted training that incorporated the difficult conversations they might encounter around patients\u0026rsquo; vaccine misconceptions or misinformation so they could learn \u0026ldquo;\u003cem\u003ewhen to stop short of an argument\u003c/em\u003e\u0026rdquo; (\u003cem\u003eP24, Female, 47, GP, England\u003c/em\u003e), or have conversation templates to use as \u0026ldquo;\u003cem\u003ea roadmap to be able to discuss with people\u003c/em\u003e\u0026rdquo; (P\u003cem\u003e12, Male, 67, GP, France\u003c/em\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003col\u003e\u003cli\u003e \u003cspan\u003e The \u003cem\u003eRevue du Praticien\u003c/em\u003e (in English: Practitioner\u0026rsquo;s Review) is a generalist medical journal.\u003c/span\u003e \u003c/li\u003e\u003c/ol\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe objective of the study was to provide insight into HCPs\u0026rsquo; experiences and perspective of vaccine communication and the associated training they had received. In semi-structured interviews with HCPs in England and France, we explored how HCPs approached vaccine conversations with patients, the challenges they had in these conversations, what training they had received to support those conversations, their perception of that training and their unmet training needs.\u003c/p\u003e \u003cp\u003eThe main approaches to and challenges with vaccine conversations were broadly similar in both countries. HCPs often had conversations with patients to provide vaccine information, which required effective communications skills. However, HCPs were not always supported with sufficient time, informational resources, and skills to confidently navigate difficult conversations with hesitant patients without risking damage to the wider patient-provider relationship that they wished to prioritise. This is consistent with other studies conducted in Ireland, the Netherlands, and Australia, which found that HCPs preferred to avoid conflict to maintain their rapport with patients (Berry et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Loftus et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Mollema et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Ruijs et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe HCPs we interviewed had received training in delivering vaccinations, with provision differing between countries. HCPs in France mostly recalled vaccine-related training occurring in earlier stages of their career, whereas HCPs in England largely described ongoing training to update their skills and knowledge. In both countries, training mostly covered practical skills and vaccine-specific knowledge, which is in line with existing literature on vaccine training provision (e.g., Kern\u0026eacute;is et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Lanza et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Public Health England, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The informational resources HCPs consulted to increase their vaccine knowledge also targeted the content of vaccine conversations rather than communication style.\u003c/p\u003e \u003cp\u003eHCPs who had attended vaccine communication training felt it was useful for dealing with communication challenges. However, the majority of HCPs we interviewed in both countries reported that they had not received such training. This was the case for both nurses and GPs. This may seem surprising since both countries include vaccine communication as a core competency: within the national standard for immunisation training in England and within physicians\u0026rsquo; compulsory medical training in France. However, England\u0026rsquo;s national standard is not mandatory (Public Health England, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) and while medical students in France are examined on vaccine communication, it does not necessarily mean medical schools have prioritised this aspect of their training (Kern\u0026eacute;is et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Indeed, previous research found that French medical students felt underprepared for questions about vaccination from patients (Kern\u0026eacute;is et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). In addition, none of the nurses interviewed in France reported receiving vaccine communication training, whereas in England, several of the nurses we interviewed had received such training.\u003c/p\u003e \u003cp\u003eHCPs commonly described accumulating communication skills through their clinical role, or applying communication training (including on motivational interviewing) that they received elsewhere to vaccination contexts. HCPs also picked up skills informally from their colleagues, which suggests that training some HCPs in a team could benefit the whole team.\u003c/p\u003e \u003cp\u003eOne specific training need highlighted was to provide help finding convincing counter-arguments to patients\u0026rsquo; misconceptions. This area was previously identified as needing more research attention (Lanza et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and we find that there is indeed a gap in training provision here. HCPs would benefit from training that targets why patients hold vaccine misconceptions and what strategies HCPs could use to successfully correct these. This training gap is especially concerning as many misconceptions held by patients stem from misinformation (Betsch et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Garett \u0026amp; Young, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Lewandowsky et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). HCPs in our sample described cases where it was difficult to challenge information from misleading sources, which patients had encountered and believed.\u003c/p\u003e \u003cp\u003eIn line with past research (Berry et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), HCPs mostly agreed that vaccine communication training would be useful for them and for their colleagues, especially junior HCPs who could benefit from acquiring relevant communication skills earlier in their careers. Thus, it seems promising that HCPs in France mentioned the offer of motivational interviewing training for medical students and interns, though it was not universally available in medical schools across the country nor to nurses. Making this type of communication training specific to vaccination would also be beneficial, as previous work has shown that training medical interns to apply motivational interviewing to vaccination conversations improved their self-efficacy (Garrison et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2023a\u003c/span\u003e), which can translate into more frequent vaccine recommendation behaviour among HCPs (Garrison et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2023b\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHCPs\u0026rsquo; preferences for training delivery reflect a tension between convenience (online training was easily accessible amidst a busy schedule) and enjoyability (face-to-face training was perceived as more engaging and an opportunity to learn through interaction with colleagues). Recent innovations in training delivery\u0026mdash;in part accelerated by the need for diverse training media during the COVID-19 pandemic\u0026mdash;have provided a range of formats and resources that could be harnessed widely to balance HCPs\u0026rsquo; competing needs (Boutros et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This would be especially helpful for HCPs who have difficulty finding suitable times to attend or travel to organised training. Having a range of online and offline resources for learning as groups or individuals, taught or self-directed, would provide flexibility for HCPs to engage in training as part of their continuing professional development. Crucially, regardless of format, training should be interactive to support HCPs\u0026rsquo; learning.\u003c/p\u003e \u003cp\u003eWithin communication training, specific needs targeting the vaccination context should be addressed. HCPs with more clinical experience or who had attended other forms of communication training expressed confidence with general communication principles, such as listening skills and demonstrating empathy. Some of them described applying these skills successfully in discussions about vaccination, but we do not know how effectively all HCPs can transfer these skills to different contexts. Training in generic communication skills could be more useful for HCPs earlier in their career, when they have not had the opportunity yet to learn from experience. Other specific and complementary skills, such as how to develop convincing responses to correct patient misconceptions about vaccines while preserving the patient-provider relationship, requires greater tailoring of informational resources (Connors et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) and sensitivity to the psychological motivations of the patient (Gagneur, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Holford et al., in press). As our interviewees described, HCPs may have a tendency to preserve relationships with their patients, sometimes at the cost of vaccine promotion. Most HCPs, regardless of their clinical expertise, are likely to benefit from developing confidence and skills tailored to handle these types of conversations, and this could increase their self-efficacy and likelihood of recommending vaccines (Garrison et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2023b\u003c/span\u003e). Moreover, vaccine-specific communication training may help to combat counterproductive communication habits such as giving information before listening to the patient (Gilkey et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) or dismissing hesitant patients (Dong et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Incorporating tailored vaccine communication into HCPs\u0026rsquo; training, for example to identify the motivations of patients and align communications with those motivations (Holford et al., in press), would also be in line with the WHO\u0026rsquo;s recommendation to tailor immunisation programmes to understand the perspectives of populations where vaccine coverage is low (Dub\u0026eacute; et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAlthough our main focus was on HCPs\u0026rsquo; communicative capability and training provision around this, many of the HCPs we interviewed also brought up systemic issues around when and where vaccine conversations take place, and how this wider structure of the vaccination environment can impact HCPs\u0026rsquo; ability to speak with patients. Communication-specific training will not overcome logistical challenges such as a lack of time or dedicated space for a conversation to happen, nor the growing shortage of HCPs that impacts on the care they can provide to patients (WHO, 2022). It is important to create these conversational opportunities within the healthcare environment. However, this must go hand in hand with preparing HCPs with competencies to engage in effective vaccine communication. Many of the HCPs we interviewed expressed high motivation to speak to patients about vaccines, but they and other colleagues who might be more wary could also increase their motivation to do so with more confidence in their abilities and confidence that patients would receive the conversation well.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eOur research offers qualitative insights about how HCPs experience vaccine conversations and training provision around this aspect of their job. However, these in-depth interviews are limited to small samples from each country, so we cannot comment on how prevalent these experiences are among HCPs. Although we recruited a diverse sample in relation to professional roles, regions, genders, and ages, our findings are still limited to a predominantly pro-vaccination sample. The opinions of HCPs who are themselves vaccine hesitant have not been represented as part of this study. Finally, our study only focused on the views of HCPs and did not include patients. We are therefore unable to assess whether HCPs\u0026rsquo; perceptions of effective communication match patients\u0026rsquo; perceived needs.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eHCPs perceived overcoming vaccine hesitancy through effective conversations as part of their professional role but identified numerous challenges to carrying out their communicative function. HCPs\u0026rsquo; training could be improved to teach various specific and complementary skills, such as how to address vaccine misinformation while also communicating in a way that preserves a trustful relationship with patients. Improving such skills may improve HCPs\u0026rsquo; motivation to engage in conversations with vaccine-hesitant patients. Training will only be effective when embedded in a supportive system and when its impact is duly evaluated. It should be implemented as part of a systemic approach that provides HCPs with skills, confidence, and logistical support to carry out their vaccine communication roles.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor notes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor the purpose of open access, the author(s) has applied a Creative Commons Attribution (CC BY) licence to any Author Accepted Manuscript version arising from this submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research received approval from the School of Psychological Science Research Ethics Committee of the University of Bristol (reference: 119594) and Ethical Committee of Aix-Marseille Universit\u0026eacute; (reference: 2022-10-20-007). The research was conducted in accordance with the principles stated in the Declaration of Helsinki. All participants gave informed consent prior to participating in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMaterials used in the study are provided as Supplementary Material to this article. Qualitative interview transcripts may be requested from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding and acknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project has received funding from the Horizon 2020 Research and Innovation Programme grant 964728 (JITSUVAX).\u003c/p\u003e\n\u003cp\u003eHF acknowledges support from the NIHR Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol. The Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation at University of Bristol is part of the National Institute for Health Research (NIHR) and a partnership between University of Bristol and UK Health Security Agency (UKHSA), in collaboration with the MRC Biostatistics Unit at University of Cambridge and University of the West of England.\u003c/p\u003e\n\u003cp\u003eEB and PV acknowledge support from CAPNET and ANRS-Emerging infectious diseases, and funding and support from the French Ministry of Health and Prevention and the French Ministry of Higher Education, Research and Innovation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions (using the CRediT system)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eD.H.: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, and Writing - original draft.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eE.C.A.: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Validation, and Writing - review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA.B.: Formal analysis and Validation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA.G.: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, and Writing - review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eH.F.: Conceptualization, Funding acquisition, Investigation, Methodology, and Writing - review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eE.B.: Data curation and Writing - review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eV.C.G.: Investigation, Project administration, and Writing - review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eP.V.: Conceptualization, Funding acquisition, Methodology, Project administration, Supervision, and Writing - review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eS.L.: Conceptualization, Funding acquisition, Project administration, Supervision, and Writing - review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBerry NJ, Henry A, Danchin M, Trevena LJ, Willaby HW, Leask J. 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Factors associated with the uptake of seasonal influenza vaccination in adults: A systematic review. J Public Health. 2016;38(4):746\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/pubmed/fdv194\u003c/span\u003e\u003cspan address=\"10.1093/pubmed/fdv194\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"vaccine communication, healthcare professionals, skills training, vaccine hesitancy, vaccine confidence","lastPublishedDoi":"10.21203/rs.3.rs-4011945/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4011945/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eHealthcare professionals (HCPs) can play an important role in encouraging patients and their caregivers to be vaccinated. The objective of this qualitative study was to investigate HCPs’ perspectives on challenges in vaccine communication and unmet training needs in this domain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eSemi-structured interviews were conducted with 41 HCPs (mainly nurses and physicians) with vaccination roles (23 in England; 18 in France), gathering information on: (1) HCPs’ approach to vaccine conversations with patients; (2) Challenges of communicating about vaccines; (3) Vaccine-related training and learning resources available to HCPs, and ; (4) HCPs’ training needs around vaccine communication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eHCPs described a range of communication experiences that indicated insufficient time, information, and skills to confidently navigate difficult conversations with vaccine-hesitant patients. Communication skills were especially important to avoid conflict that could potentially damage the patient-provider relationship. Some HCPs interviewed had received communication training, but for most, this training was not specific to vaccination. Although general communication skills were transferable to vaccine conversations, most HCPs welcomed specific training and informational resources to support countering patients’ misconceptions or misinformation about vaccines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eHCPs would benefit from training tailored to address vaccine communication with patients, and this should be part of a systemic approach that also provides time and space to have effective vaccine conversations.\u003c/p\u003e","manuscriptTitle":"Healthcare professionals’ perceptions of challenges in vaccine communication and training needs: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-26 12:07:04","doi":"10.21203/rs.3.rs-4011945/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-29T16:27:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-06T06:13:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-03T13:18:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9e6f2754-4747-4c4b-bd93-a0dd9c16d336","date":"2024-04-22T07:43:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"b2e9d219-f66e-4aac-af63-48f788d2d7b7","date":"2024-04-21T23:13:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-21T12:45:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-03-27T08:54:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-22T10:17:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-22T10:17:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2024-03-04T12:15:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d551a96d-1582-40f8-b52b-8c44d749b294","owner":[],"postedDate":"March 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-01T17:15:51+00:00","versionOfRecord":{"articleIdentity":"rs-4011945","link":"https://doi.org/10.1186/s12875-024-02509-y","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2024-07-20 16:13:43","publishedOnDateReadable":"July 20th, 2024"},"versionCreatedAt":"2024-03-26 12:07:04","video":"","vorDoi":"10.1186/s12875-024-02509-y","vorDoiUrl":"https://doi.org/10.1186/s12875-024-02509-y","workflowStages":[]},"version":"v1","identity":"rs-4011945","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4011945","identity":"rs-4011945","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}