During the 2019 coronavirus– (COVID-19) pandemic, the importance of immunization was well recognized. Immunization has been an essential strategy to decrease the spread of the virus globally and improve mortality and morbidity associated with COVID-19. However, some people have negative perceptions of immunization due to safety concerns and anxiety about adverse reactions to the new COVID-19 vaccines, which were created in a short period of time. Vaccine hesitancy or refusal has become one of the most important and controversial issues in recent years [1
]. Vaccine hesitancy is defined based on the Strategic Advisory Group of Experts on Immunization (SAGE) as a “delay in acceptance or refusal of vaccination despite the availability of vaccination services” [2
]. It is a complex and context-specific phenomenon, varying by time, place, and vaccine, and it is influenced by factors such as complacency, convenience, and confidence [3
Healthcare workers (HCWs) are expected to be aware of the risks and benefits of vaccination as well as the risks of vaccine-preventable diseases (VPD), and they should be able to communicate that information to caregivers in the most appropriate manner. Many developed countries have their own communication tools and provide parents with standardized education related to immunization. For example, education on infant immunization is systematically and routinely provided in the United States [4
]. In other developed countries, informing parents of the risks and benefits of vaccines is the usual approach and is legally mandated [1
]. However, in Japan, there are various ways to convey such information, and the content of immunization education varies among HCWs [7
]. This is most likely because individual HCWs did not receive sufficient education related to immunization when they were trained.
Our previous study in Japan from 2014 demonstrated the deficiencies in the available infant immunization content in terms of both quality and quantity [8
]; specifically, parents were unable to make optimal decisions on whether to administer voluntary vaccines to their children after receiving such information [8
]. Although studies have identified HCWs as important sources of immunization information [9
], understanding their attitudes toward vaccination is crucial. Researchers have reported that HCWs lack the confidence to provide vaccination information and recommendations to their patients [11
]. A study demonstrated that HCWs in some European countries, including Croatia, France, Greece, and Romania, displayed vaccination hesitancy [15
]. There also exists a strong relationship between the knowledge and attitudes of HCWs regarding vaccines and their vaccine recommendations for their patients [16
]. If HCWs are hesitant, they might recommend vaccines less frequently or undermine patients’ confidence in them, thus contributing to patients’ vaccine hesitancy [11
]. On the other hand, increased knowledge and positive attitudes toward vaccination among nurses have been positively associated with increased vaccination coverage [17
]. Additionally, a positive association between nurses’ own vaccination status and their reported promotion of vaccinations to their patients has been reported [14
The perceptions and attitudes of HCWs toward immunization can vary among professionals [18
]. Although there have been studies on the differences in attitudes among providers toward immunization [9
], few studies have characterized the nature and extent of vaccine hesitancy among HCWs. Therefore, this study investigated current practices in childhood immunization education in Japan and clarified HCWs’ attitudes toward childhood vaccination, focusing on vaccine hesitancy.
The present study examined current vaccination practices and sought to clarify attitudes that engender vaccination hesitancy across different HCWs in Japan. These findings are important for identifying vaccine-related concerns, understanding the attitudes among HCWs, and finding which HCWs are the most hesitant toward childhood vaccinations, which illustrates different reasons for vaccine hesitancy among HCWs.
Regarding childhood immunization, the information sources among HCWs vary, stemming from differing educational backgrounds on immunization. Although our results demonstrated that pediatricians have access to reliable information resources, nurses rely on different resources, including mass media and information from other HCWs, which might be biased. In general, nurses have fewer opportunities to learn about immunization during school or post-graduate training. The findings of this study indicate that the HCWs need to improve their knowledge through increased access to reliable immunization information. A previous study showed that among HCWs, greater intentions to vaccinate and more favorable attitudes toward vaccination were associated with higher awareness and positive beliefs that were more aligned with scientific evidence [19
]. The results of this study concur with this prior study. Unfortunately, no official, standardized learning tool for immunization education for HCWs is currently available in Japan; hence, HCWs inevitably pursue individual learning opportunities using different resources, which could result in an increased information gap. Securing educational opportunities for HCWs through immunization policies should be considered as a way to create well-informed HCWs.
We demonstrated that more than half of HCWs provided 1 to 5 min of immunization education to parents or caregivers; however, this duration is considered insufficient [8
]. In a nationwide survey in the United States, physicians and nurses reported spending an average of 3 min discussing vaccine risks and benefits with parents [20
]. In the current study, midwives provided immunization education to parents for 6–10 min, which was more than the time spent by any other type of HCWs. Studies have reported that when HCWs have accurate immunization information based on scientific evidence, along with a positive attitude toward vaccination, they are more likely to engage in and provide positive information regarding vaccination [20
]. Considering all the different sources of immunization information, updating the relevant information with the latest evidence-based knowledge is crucial. Nurses have more frequent opportunities to educate parents about immunization than other HCWs, such as during newborn home visits and one-month post-partum check-ups. As such, nurses have a significant impact on the vaccination decision-making of parents and caregivers, even for those who believe vaccines are unsafe [24
]. Therefore, nurses should acquire accurate and reliable scientific information regarding an immunization to improve parents’ confidence in vaccination. This needs to be provided by other HCWs, especially physicians who interact with nurses.
All HCWs involved in infant immunization should receive sufficient information to serve as educators and guarantee that the instructions provided to parents are of high quality. The duration, content, location, and individuals responsible for immunization education varied across HCWs, indicating that immunization information is neither standardized nor efficiently communicated in Japan. A study suggested that a team approach to immunization education by physicians and nursing staff needs to be recognized, coordinated, and strengthened [21
]. Thus, multidisciplinary collaboration is required to achieve a unified education system. The HCWs involved in immunization should receive standardized instructions to ensure that they provide consistent guidance. Therefore, the content and implementation of educational programs should be improved, and information should be shared among the concerned disciplines.
In the current study, for the first category, contextual, pediatricians were found to be more concerned about the national vaccine policy than all nursing professionals including midwives, public health nurses, and registered nurses. One possible reason for this is that nursing professionals might be less interested in and knowledgeable about national vaccine policies. Interestingly, midwives were significantly less likely to recognize the health risks stemming from non-vaccination for religious and cultural reasons. Several studies have shown that midwives have specific perceptions and attitudes toward immunization compared to the relatively more institutionalized sentiments of other HCWs. For example, whereas pediatricians were found to be supportive of immunization programs, midwives reported various levels of support [19
], and they were often more concerned about trust in vaccines and vaccine methods [28
Regarding the second subcategory, namely personal cognition and socio-environmental factors, there were significant differences between public health nurses, midwives, registered nurses, and pediatricians in items related to knowledge, such as concern about immune overload, lack of awareness about the severity of natural infection, and poor understanding of vaccination schedules. Nursing professionals had more concerns than did pediatricians. It was further found that pediatricians had lower vaccination hesitancy than did nursing professionals for most items.
This current finding is consistent with the results of previous studies regarding the concerns of midwives [22
] and reports that public health nurses and midwives can have significantly different opinions from pediatricians on items related to knowledge, such as awareness of the severity of natural infections, social defense, and herd immunity. Previous studies have reported that knowledge acquisition and positive beliefs by HCWs may lead to positive changes among patients [17
]. Therefore, educating HCWs is necessary to secure the quantity and quality of knowledge related to immunization. Furthermore, we found that both midwives and public health nurses tended to have similar concerns.
In terms of the third category, factors directly related to vaccination, the nurses’ concerns about over-vaccinating children were also significantly higher than the pediatricians’ concerns. A previous study in Canada showed that most midwives believed that vaccination begins too early in life [8
]. Further verification is needed to determine whether this is due to differences in knowledge or related to other factors.
This study has some limitations. First, the number of subjects in the study was small, which may have decreased the likelihood of detecting potential differences, and the generalizability of the findings might be limited. A further study with a larger number of study subjects in different geographic areas needs to be conducted. Second, the study population was recruited from one geographical area, limiting the generalizability of the findings to all HCWs in Japan. Third, potential selection bias may exists given the limited response rates and sample size of the survey, which might have affected the validity of the results. The findings, therefore, may not represent the trends among HCWs in Japan. Fourth, the age of the HCWs differed significantly; differences in experience among professionals may affect the knowledge and attitudes of HCWs. Finally, causal relationships cannot be identified in this cross-sectional study; thus, further longitudinal research is necessary to determine professional attitudes that affect the actual patient vaccination rate and the extent to which these correlate with HCWs’ knowledge of vaccination. However, despite these limitations, this study illuminates the nature of hesitancy among HCWs involved in immunization in Japan. Directions for future study include linking provider attitudes, knowledge, and educational practices directly to outcome variables, such as vaccine acceptance, coverage, or parental satisfaction with immunization services.
In conclusion, most HCWs reported spending time communicating about vaccines; however, the time was limited, and they did not appear to have received sufficient information about immunization in infants and children. Overall, nurses, especially registered nurses, tended to have more negative attitudes toward vaccination and limited awareness of immunization promotion compared to pediatricians. All HCWs involved in the immunization of infants and children need to receive adequate information so that they can serve as educators, thus ensuring the superior quality of the instructions provided. Future research could explore specific factors related to vaccine hesitancy, providing insight into the differences in hesitancy and the need for a more comprehensive education for each type of HCW.