Experiences of Malaysian primary healthcare providers with vaccine hesitancy: A qualitative study

Abstract Introduction: Vaccine hesitancy was declared as one of the ten threats to global public health by the World Health Organization in 2019. It undermines the effort towards eradication of vaccine-preventable diseases. Healthcare providers, who are directly involved in vaccination services and vaccine advocacies, are important in combating vaccine hesitancy. Studies have shown that vaccine refusers have various reasons for refusal including distrust towards healthcare providers. Hence, it is important to understand healthcare providers’ perspectives. This study aimed to explore primary healthcare providers (PHCPs)’ experiences in dealing with vaccine hesitancy. Methods: This qualitative study was conducted among public PHCPs across six states in Malaysia. Purposive and snowball sampling methods were used. Fifteen primary healthcare doctors and nurses underwent in-depth interviews. Recruitment was stopped when data saturation was achieved. Data were thematically analysed. Results: Four themes emerged: 1) views towards vaccination and vaccine hesitancy, 2) disparity in strategies and resources used among PHCPs, 3) fixed-minded vaccine deniers and religious incompatibility: the two towering hurdles and 4) negative impact after encounters with vaccine hesitancy. Conclusion: Malaysian PHCPs encounter negative experiences with vaccine hesitancy, impacting them negatively. These experiences are attributed to the challenges and lack of standardised resources for reference. These findings suggest the development of a more flexible policy, a training module inclusive of all professional roles and a standardised repository of resources for managing vaccine hesitancy.


Introduction
Vaccine hesitancy, de ned as the reluctance or refusal to receive vaccination despite the availability of vaccines, was declared by the World Health Organization (WHO) as one of the threats to global public health in 2019. 1,2t is a barrier to the eradication of vaccinepreventable diseases.e progress towards the Global Vaccine Action Plan target of at least 90% coverage for all assessed vaccines in 2019 is stalled or even reversed in certain countries. 3s such, the incidence of vaccine-preventable diseases due to vaccine hesitancy is increasing and is especially alarming in Muslim countries including Malaysia. 4Locally, vaccine hesitancy has led to an increase in vaccine-preventable diseases and the emergence of eradicated diseases such as poliomyelitis. 5As con dence towards vaccination includes con dence towards service providers, distrust towards healthcare providers is one of the reasons for vaccine refusal. 6s is perturbing, as the WHO views healthcare providers, especially those working in the community, as the in uencers of vaccination decisions. 1laysia is a developing, multi-ethnic and multireligious country in Southeast Asia.e majority of the population in the country is Muslim.Religious incompatibility has been described as another factor in uencing vaccine acceptance. 7As Malaysian primary healthcare providers (PHCPs) may have di erent religions to their client, understanding the dynamic of this relationship is important.In general, Malaysian childhood vaccination service is provided mostly by the public health facilities, subsidised by the government 8 .PHCP in public health clinics are the main vaccine service providers.e current local guideline highlights the referral system should the clients refuse vaccination. 9 rst point of counselling starts with nurses and escalates to medical o cers and then to family medicine specialists (FMSs) should clients still refuse vaccination.is system has caused discomfort among parents, as they view repeated visits as coercion towards them.10 It is important to understand healthcare providers' experiences with vaccine hesitancy in Malaysia and the impact of these experiences on them.ese views will provide insights into the relationship between vaccine-hesitant parents and healthcare providers, ultimately aiding in the development of guidelines and strategies for addressing vaccine hesitancy.

Study design
is study utilised a qualitative approach.e integrated behavioural model (IBM) was used as the theoretical framework to understand PHCPs' behaviour towards vaccine hesitancy.
e constructs of the IBM were used to explore PHCPs' experiences including the challenges encountered, strategies employed and impacts observed in dealing with vaccine hesitancy. 11

Study setting and participants
e study was conducted from March to October 2021 in public health clinics across six states in Malaysia whose incidence of vaccine refusal varied.
e participants were PHCPs including FMSs, medical o cers and nurses working in the selected clinics.e inclusion criteria were 1) at least one encounter with vaccine hesitancy in their practice and 2) the ability to converse in either English or Malay.

As per the Malaysian National Childhood Immunisation
Programme, vaccination starts on the rst day of life. 8After newborns are discharged, home visits are conducted by community nurses nine times up to 20 days of puerperium. 12s is usually the rst contact of PHCPs with vaccine-hesitant parents.Community nurses then counsel parents and refer them to medical o cers and then to FMSs should counselling fail.Occasionally, registered nurses and nursing sisters are involved prior to referral to medical o cers.Nursing sisters have more training and experience than registered nurses and registered nurses than community nurses.

Sampling and recruitment
Participants were recruited via purposive and snowball sampling methods.FMSs with known involvement in vaccine hesitancy advocacies were approached to participate and asked to suggest other participants.Advice from state health departments about clinics with high vaccine hesitancy rates was also sought.

Data collection
Data were collected via in-depth interviews (IDIs) to encourage active participation and expression of opinion without in uence and pressure from di erences in hierarchy.All interviews were conducted by the principal researcher.In view of the COVID-19 pandemic, the IDIs were conducted via teleconferencing using a secure audio-visual platform (i.e.Zoom), which was encrypted to ensure data security. 13 interviews were conducted in the preferred language of participants and recorded using an audio recorder.Field notes were taken to aid analysis.Sampling was stopped after data saturation was attained.14 Data analysis e audio recordings were transcribed verbatim, coded and analysed in their original languages.Malay words or sentences were translated into English by the researchers for reporting purposes.Content analysis was conducted with the aim of developing themes.15 e two researchers analysed the transcripts independently and then discussed and agreed on the coding framework.
ereafter, the code groups were organised into a list of themes that were produced as the nal results of the data analysis.
Several strategies were employed to ensure research rigour.Triangulation was conducted by obtaining data from various professional positions and social backgrounds.A log of the research process was kept to ensure an audit trail.e decision on the methodology and interpretive judgement of the data analysis were noted with their justi cations.A nal discussion was carried out between the researchers regarding the list of themes to ensure a neutral interpretation and prevent researcher bias.

Participant demographics
A total of 15 participants ( ve FMSs, four medical o cers, ve nurses and one nursing sister) were interviewed.
eir ages ranged from 31 to 53 years.irteen participants were Muslims, while the remaining two were Hindus (Table 1).
e participants were recruited from seven public health clinics across six states: Johor (n=5), Sabah (n=3), Terengganu (n=3), Kedah (n=2), Kuala Lumpur (n=1) and Selangor (n=1).ey perceived vaccine refusal as an irresponsible choice, as it may a ect the community, hence leading to negative emotions in dealing with vaccine hesitancy.

eme 2: Disparity in strategies and resources used among PHCPs
e PHCPs reported no standardised method for handling vaccine hesitancy.
e doctors received regular training and tended to be more equipped in terms of reference and skills.In contrast, the majority of the nurses were not trained and used non-credible resources as reference.
is led to their self-perceived inferiority in dealing with vaccine hesitancy despite being the rst to encounter it.

eme 3: Fixed-minded vaccine deniers and religious incompatibility: the two towering hurdles
e PHCPs shared that xed-minded vaccine refusers are often uncooperative.
e PHCPs were forced to deal with them repeatedly due to the rigid standard operating procedure (SOP).Despite maximal e ort and time spent, it was di cult to persuade xed-minded refusers.Additionally, religion was reported by the PHCPs as being used often by their clients in refusing vaccination, which became more profound when the counselling PHCPs came from a di erent religion.

eme 4: Negative impact after encounters with vaccine hesitancy
e negative perception towards vaccine hesitancy, propagated by the repeated negative experiences surrounding their encounters, led to frustration among the PHCPs. is perception was worsened by the low rate of success, leading to reductions in the morale and negative e ects on the professional practice of the PHCPs.

Discussion
Vaccine hesitancy is a spectrum.Fixed-minded vaccine refusers encountered by PHCPs are likely to be vaccine deniers.
e group at the end of the vaccine hesitancy spectrum has a substantially negative attitude towards vaccination and is not willing to change despite scienti c explanations. 16Encountering these clients causes internal con icts when PHCPs try to balance their obligations towards individual decisions and the necessity to prevent communicable disease transmission in the community. 17is leads to frustrations, which become more prominent among encounters with parents who are unwilling to even engage in discussions.
Religious concerns are one of the reasons for vaccine refusal. 10,18s reason emerges even among PHCPs and clients who share the same religion, and it becomes more prominent when they do not.PHCPs may respond to this through various manners, most notably by providing more medical information and discussing the decision-making process. 19owever, as religion a ects clinical practice, 20 religious disparity may not only cause discomfort among PHCPs and clients but also lead to suboptimal attempts of communication regarding vaccination.Without intervention, this aspect may deepen the misunderstanding of religious incompatibility, especially in multireligious countries such as Malaysia.
Choosing to dismiss vaccine deniers and focusing only on fence-sitters were not possible for the participants in this study.As PHCPs are working in public healthcare facilities, they are required to adhere to the rigid SOP for vaccine hesitancy. 9Due to the hierarchical escalation system, vaccine refusers will not be dismissed until maximal e ort is given to convince them.
is may be di erent with healthcare providers working in the private sector, as it has been shown that they are more likely to dismiss vaccine-refusing clients. 21Conversely, the referral system bene ts vaccine-hesitant clients by ensuring that they have maximal information and explanation to make an informed decision.However, this approach puts both clients and sta in discomfort due to repeated stressful negative encounters.e resources used were not standardised and di ered greatly among the nurses and doctors who participated in the study.At the time of the study, there were no speci c guidelines or a standardised information repository for communicating with vaccine refusers in Malaysia.Although the doctors used credible resources, it was worrying that the nurses used Google and YouTube to assist them, as the usage of di erent keywords may lead to false information regarding vaccination. 22More than half of internet users have been reported to perceive vaccination-related information obtained from the internet as accurate, even though it is incorrect half of the time. 23Hence, by not having standardised sources of credible information, nurses may provide inaccurate information to vaccine-hesitant parents and pose more challenges for future consultations.
All of the abovementioned factors generally result in a negative experience among PHCPs in dealing with vaccine hesitancy.e perceived bene t that vaccination prevents diseases and outbreaks and confers herd immunity 24 is challenged when they encounter vaccine hesitancy.
is negative experience has a signi cant impact.
e feelings reported by PHCPs t the three components of burnout syndrome. 25Being scolded by clients is one of the signi cant contributing factors to burnout. 26Loss of autonomy at work and decreased control over the work environment, wherein nurses are coerced to meet vaccine refusers repeatedly, add to the negative impact noted. 27Consequently, the negative impact a ects their practice, possibly leading to medical error and a decline in patient safety. 28 study is limited by the variability of the participants.Out of 2863 public health clinics in Malaysia, only seven were included.29 Private practitioners were not interviewed, and only two religions were represented.Nevertheless, as this study focused on understanding the experiences and challenges in vaccine hesitancy counselling, the source triangulation among the PHCPs of varying professional positions and social backgrounds provided rich insights.
In conclusion, Malaysian PHCPs mostly have negative experiences with vaccine hesitancy particularly in dealing with xed-minded vaccine refusers, worsened by the rigid existing policy and religious disparity.Actions should be taken to revise the current hierarchical escalation system, especially in dealing with di erent spectrums of vaccine hesitancy.In addition, a standardised training module How does this paper make a di erence in general practice?
• is study provides insights into the negative experiences of public primary healthcare providers in Malaysia in dealing with vaccine hesitancy.• e rigid existing policy causes repetitive encounters of primary healthcare providers with xed-minded vaccine deniers and impairs the relationship between both parties.• e lack of standardised resources causes disparity in managing vaccine hesitancy among public healthcare providers.• e religious disparity that occurs even within the same religion causes communication roadblocks in vaccine hesitancy counselling.
• Understanding the abovementioned factors can help in designing a more pragmatic policy that is more understanding towards both providers and clients.
and a vaccination information repository should be developed to prepare PHCPs, including both doctors and nurses, to manage vaccine hesitancy.Cooperation with religious authorities and individuals should be sought to manage the religious concerns related to vaccine hesitancy in multireligious countries such as Malaysia.Lastly, further studies comparing the knowledge, attitude and con dence towards vaccines between providers and clients should be conducted to understand the impact of any disparity.
emes e themes, subthemes and representative quotes are summarised in Table2.
'… e previous FMS, he pressured us too much.at time all the sta were stressed.e (nursing) sister and matron had to follow.We had to go (home visit) for as long as the mother refuse to come'.-P8