A Behavioral analysis of nurses’ and pharmacists’ role in addressing vaccine hesitancy: scoping review

ABSTRACT

The purpose of this review was to identify, characterize, and map the existing knowledge on a) nurses’ and pharmacists’ perceived barriers and enablers to addressing vaccine hesitancy among patients; and b) strategies or interventions for nurses and pharmacists to address vaccine hesitancy in their practice. Our comprehensive search strategy targeted peer-reviewed and grey literature. Two independent reviewers screened papers and extracted data. We coded narrative descriptions of barriers and enablers and interventions using the Behavior Change Wheel. Sixty-six records were included in our review. Reported barriers (n = 9) and facilitators (n = 6) were identified in the capability, opportunity and motivation components. The majority of the reported interventions were categorized as education (n = 47) and training (n = 26). This current scoping review offers a detailed behavioral analysis of known barriers and enablers for nurses and pharmacists to address vaccine hesitancy and interventions mapped onto these behavioral determinants.

KEYWORDS:

• Vaccine hesitancy
• nurses
• pharmacists
• immunization
• barriers
• enablers
• behavior change whee

Introduction

Immunizations are considered one of the greatest public health achievements of the 20th century,¹,² preventing two to three million deaths globally per year. Despite the success of immunization programs,³ vaccine acceptance has often been met with varying levels of vaccine resistance or hesitancy.⁴ Vaccine hesitancy is defined as a delay in acceptance or refusal to vaccinate despite the availability of vaccines.⁵ Vaccine hesitancy is believed to be responsible for decreases in vaccine coverage and increased outbreaks of vaccine-preventable diseases.⁶ In fact, the World Health Organization (WHO) identified vaccine hesitancy as one of the biggest threats to global health in 2019;² the threat that global vaccine hesitancy has on herd immunity can cause significant, negative public health outcomes.¹ This is particularly concerning given the current COVID-19 pandemic and variants of concern; mass vaccination of the general public will be needed to contain and prevent future spread of COVID-19. In order to create herd immunity for the population, it is expected that the COVID-19 vaccine will need to be accepted by a vast majority of the population in Canada, with some estimates expecting at least 85% depending on the country and infection rate.^7,8 To effectively combat COVID-19 and other vaccine-preventable diseases, effective strategies are needed to counter vaccine hesitancy.

Health-care providers are well situated in health systems to address vaccine-related concerns and hesitancy. Nurses and pharmacists, in particular, often have more dedicated time to talk with concerned individuals or parents of children prior to vaccine administration, compared to physicians and other health-care providers.⁹ Multiple strategies and interventions have been employed to address vaccine hesitancy and, therefore, increase vaccine uptake, including provider-based interventions.¹⁰ Of the known provider-based interventions, there is a range of techniques used, from informative conversations about vaccines with patients and/or parents,^11,12 the use of prevalence statistics to educate patients and/or parents,¹³ and practicing empathetic communication.¹⁴ These interventions have been shown to be effective techniques in shifting vaccine hesitant patients and/or parents to vaccine acceptors.^11–14

Despite these evidence-based interventions to address vaccine hesitancy, little is known about how provider-based interventions are implemented into nurses’ and pharmacists’ practice in the community and hospital setting. In health care, more broadly, studies have shown that barriers at the individual, interpersonal, organizational, and system levels can significantly hinder the implementation of effective health-care interventions into practice.¹⁵ However, it is unclear what barriers and enablers affect nurses’ and pharmacists’ ability to address vaccine hesitancy and/or refusal among their patients. Further, it is not known how existing interventions target known barriers and utilize enablers to change, if at all. Research efforts should aim to clearly understand the barriers and enablers in order to tailor interventions to support nurses’ and pharmacists’ ability to address vaccine hesitancy and/or refusal.

As such, adopting a systematic, theory-informed approach is needed to 1) identify barriers and enablers to addressing vaccine hesitancy and/or refusal at multiple levels (i.e., individual, social, cultural, political, etc.) and 2) design implementation strategies to overcome these barriers and enhance the enablers to address vaccine hesitancy. To target barriers and enablers to addressing vaccine hesitancy, a theory-based analysis is needed to better understand the relationship between these factors, and the mechanisms in which they influence behavior.¹⁶ Studies have found that the use of theory-based approaches to behavior change can lead to more successful implementation and intervention success.^17,18

Research purpose

The purpose of this scoping review was to identify, characterize, and map the existing knowledge on a) nurses’ and pharmacists’ perceived barriers and enablers to addressing vaccine hesitancy among patients; and b) strategies or interventions for nurses and pharmacists to address vaccine hesitancy in their practice. Findings from this review will inform the design of behavioral interventions to support nurses’ and pharmacists’ practice in addressing vaccine hesitancy among their patients.

Review question(s)

1. What are nurses’ and pharmacists’ perceived barriers and enablers to addressing vaccine hesitancy and/or refusal among patients and/or the general public?

   1. How do the barriers and enablers map onto the COM-B Model?

2. What strategies exist for nurses and pharmacists to address vaccine hesitancy and/or refusal among patients and/or the general public?

   1. How do the strategies map onto the Behavior Change Wheel?

Inclusion criteria

Participants

This review considered literature that included nurses (licensed practical nurses, registered nurses, nurse practitioners, nursing students) and/or pharmacists, including pharmacy students and pharmacy technicians, as participants.

Concept

We included literature that explored perceived barriers and enablers reported by nurses and/or pharmacists to address vaccine hesitancy and/or refusal among patients, families, or the general public. For this review, an enabler is defined as “a person or thing that makes something possible,”¹⁹ whereas a barrier is defined as “a circumstance or obstacle that keeps people or things apart or prevents communication or progress.”²⁰

This review focused on strategies or interventions that have been implemented and/or evaluated to support nurses and/or pharmacists to address vaccine hesitancy and/or refusal among patients, families, or the general public. Strategies or interventions refer to processes, methods, or tools that were implemented or evaluated to promote or improve nurses’ and pharmacists’ ability to address vaccine hesitancy and/or refusal.

Context

This review considered studies located in any care setting, including hospital, community, primary care, ambulatory care settings, and long-term care. To maintain a focused scope of review, studies were limited to countries with similar approaches to health care (i.e., Canada, United States, United Kingdom, Europe, New Zealand, and Australia).^21,22

Types of sources

This scoping review considered both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies will be considered for inclusion. This review also considered descriptive observational study designs, including case series, individual case reports, and descriptive cross-sectional studies for inclusion.

Qualitative studies were also considered that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research, and feminist research.

Systematic reviews that report on aspects of nurses’ and pharmacists’ role in addressing vaccine hesitancy were reviewed for primary studies that may meet the eligibility criteria.

Text and opinion papers, as well as other published materials including case studies and relevant academic publications, such as theses and dissertations, were also considered for inclusion. Official websites of public health organizations in the aforementioned geographic regions and health-care provider associations were used, together with white papers, reports, position papers, and policy papers, relevant to governmental guidance. Only studies published in English were included. No date restriction was implemented to allow for the observation of any trends or changes in vaccine hesitancy over time to be captured.

Methods

This review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews.²³ JBI is an international research organization focused on Health and Medical Science evidence synthesis to improve health-care practices and health outcomes. There was no patient or public involvement in the design, conduct, reporting, or dissemination plans of this research.

Search strategy

The search strategy was developed with a JBI-trained medical research librarian scientist and aimed to locate published empirical studies and grey literature. The scoping review followed the three-step, iterative process in accordance with the JBI Scoping Review Methodology.²⁴ The three steps include 1) an initial limited search of at least two appropriate online databases relevant to the topic (MEDLINE and CINAHL), followed by an analysis of the text words contained in the title and abstract of retrieved papers and of the index terms used to describe the articles, 2) a second search using all identified keywords and index terms, and 3) searching the reference list of all identified reports and articles for any additional sources. The search strategy aimed to identify both published primary studies, reviews, and text and opinion papers.

Information sources

The databases searched include MEDLINE, CINAHL, EMBASE, Web of Science, and PsycInfo. Sources of unpublished studies and grey literature were searched using ProQuest Dissertations and Theses Global and the first 10 pages of Google Scholar. We also searched for grey literature using the Canadian Agency for Drugs and Technologies in Health grey literature checklist Grey Matters: a practical tool for searching health-related grey literature.²⁵ Relevant organizational, governmental, and health-care association websites were reviewed including, Children’s Healthcare Canada, Canadian Nurses Association, Canadian Pharmacists Association, National Association of Pharmacy Regulatory Authorities, American Academy of Pediatrics, American Pharmacists Association, Canadian Pediatric Society, Immunize Canada, Canadian Immunization Research Network, Public Health Agency of Canada, Infection Prevention and Control, Royal College of Pediatrics and Child Health, National Institute for Health and Clinical Excellence, American Nurses Association, American Pharmacists Association, Australian Nursing and Midwifery Association, Pharmacy Board of Australia, British Nursing Association.

Study selection

Following the search, all identified records were collated and uploaded to Covidence,²⁶ a citation management platform, and duplicates were removed. Two of three independent reviewers (JL, HG & LS) screened the titles and abstracts against the inclusion criteria for the review. Potentially relevant papers were retrieved in full, and their citation details imported into Covidence. Next, two of four independent reviewers (JL, HG, LD & RD) assessed the full text of selected citations in detail against the inclusion criteria. Reasons for exclusion of full-text papers were recorded and reported. Any disagreements that arose between the reviewers at each stage of the selection process were resolved through discussion or with a third reviewer (CC).

Data extraction

Data were extracted from included studies by two independent reviewers using a data extraction tool developed by the research team (see Supplemental file 2). Study information extracted included author(s), year of publication, country of origin, study aim/purpose, study population, study setting, design, outcome measures, barriers, enablers, description of strategies/interventions, reported key findings, and implications. The draft data extraction tool was piloted on five studies by two reviewers. After pilot testing, three additional items were included in the tool; population to be vaccinated, vaccine type, and study limitations. Any disagreements that arose between the reviewers were resolved through discussion or with a third reviewer.

Data synthesis and analysis

All data were combined to provide one complete dataset for analysis and cleaned by one reviewer (JL). Data on strategies/interventions and barriers/enablers were analyzed using the Behavior Change Wheel (BCW) as a coding guide. The BCW is a synthesis of 19 existing behavior change frameworks that offers a comprehensive and systematic guide to designing interventions.²⁷ The BCW (see Figure 1) includes an analysis of the nature of behavior, the mechanisms that need to be addressed in order to create behavior change, and the interventions and policies required to change these mechanisms. The BCW uses the COM-B model, which proposes that one needs Capability (C), Opportunity (O), and Motivation (M) to perform a Behavior (-B), to obtain a better understanding of the behavior in context, which is known as a behavioral analysis.²⁷ The BCW also includes nine intervention functions that are likely to be effective in bringing about behavior change in each COM-B domain.²⁷ An intervention function is defined as the function most likely to be effective in changing a particular target behavior²⁷The BCW’s behavioral analysis is an important first step in designing and implementing theory-informed interventions. To our knowledge, this type of behavioral analysis has not been conducted in the context of nurses’ and pharmacists’ role in addressing vaccine hesitancy and/or refusal among patients.

Figure 1. Behavior change wheel.

First, we conducted a behavioral analysis of nurses’ and pharmacists’ perceived enablers and barriers to addressing vaccine hesitancy. One reviewer categorized the extracted barriers and enablers into the six sub-components of the COM-B Model of behavior: (psychological capability, physical capability, social opportunity, physical opportunity, automatic motivation, and reflective motivation (Figure 1). Barriers and enablers can be categorized into multiple sub-components. A second reviewer (CC) verified all coded data. Next, the primary reviewer (JL) examined the data further and inductively generated themes on similar statements that represent the barriers and enablers within each COM-B component. All inductive codes were verified and approved by the second reviewer (CC). Discussion between the reviewers (CC & JL) was consistent throughout all steps. We presented the preliminary themes to the research team for refinement.

Second, we classified the strategies/interventions aimed at addressing vaccine hesitancy according to the BCW’s nine intervention functions (education, training, modeling, enablement, environmental restructuring, persuasion, restrictions, coercion, incentivization) (Figure 1). An intervention could be classified into one or more intervention function. One reviewer conducted the data classification using a pre-defined coding manual based on definitions and guidance from the BCW.²⁷ A second reviewer verified all data classification. Final BCW categorizations were reviewed and discussed with the entire research team. Given the focus of this scoping review on mapping existing literature, we did not explicitly perform a risk of bias assessment.

The extracted data were presented in a tabular form that aligns with the study’s objective. Results were classified under the main conceptual categories: study characteristics (including country of origin, study population, population to be vaccinated, vaccine type, study setting, design); outcome measures; barriers; enablers; strategies/interventions; reported key findings; and implications. The PRISMA-ScR²⁸ reporting guidelines were followed for reporting of this scoping review.

Results

We identified 1247 records through our database search and 100 through additional sources (e.g. grey literature). Following title and abstract screening and full-text review against the eligibility criteria, a total of 66 records were identified that met inclusion criteria and were included in this review. See Figure 2 for the PRISMA flow chart and Table 1 for characteristics of included citations. The majority of the included records were conducted in the United States (US) (n = 43) and employed a variety of research designs including reviews (mixed, integrative, systematic, literature) (n = 10), qualitative (n = 9) and informative/descriptive (n = 9). A majority of the studies were published after 2015 (n = 52), with 16 identified articles published in 2019 alone. The settings included primary care (n = 12), pharmacies (n = 10), and schools (n = 8). The most frequently targeted population to be vaccinated was children (n = 10), followed by the general population (n = 6); 20 did not specifically state the target population. The majority did not clearly state a specific vaccine (n = 47), while some focused on HPV (n = 7) and influenza (n = 5). Most were conducted with nurses (n = 49), including nurse practitioners (n = 6), school nurses (n = 4) and pediatric nurses (n = 4). Seventeen were conducted with pharmacists but did not differentiate the setting in which the pharmacist worked.

Table 1. Characteristics of included records

Authors	Country	Study aim/ purpose	Study design	Population	Population to be vaccinated	Setting
American Pharmacists Association^Citation29	USA	Prepare pharmacists to engage in productive conversations with patients about immunizations.	Informative/ Descriptive	Pharmacists	General Population	Pharmacies
Anderson et al.^Citation30	USA	Review the origin of vaccine hesitancy, explores common misconceptions about vaccine hesitancy	Review	Nurses	Children	Primary Care
Anderson^Citation31	USA	Address how nurse practitioners can improve vaccination rates by developing trusting relationships with parents and being armed with information based on sound clinical evidence.	Informative/ Descriptive	Nurse Practitioners	Children	NR
Apfel et al.^Citation32	Europe	Provide practical evidence-based and peer- reviewed advice for public health programme managers and communicators involved with immunization services	Informative/ Descriptive	Nursing Managers	NR	Primary healthcare, hospitals
Bernard et al.^Citation33	Australia	Examine the experience of fear, the fear response, and factors affecting fear in adolescents undergoing school-based HPV vaccination.	Qualitative	Immunization Nurses	Adolescent females	School
Berry et al.,^Citation34	Australia	Understand the challenges faced and strategies used when general practitioners and immunizing nurses encounter parents who choose not to vaccinate their children.	Qualitative	Practice or Community Nurses	Children	Primary Care
Black et al.,^Citation35	Canada	Determine if a public health nurse intervention to addressing/ promoting influenza immunization is effective	RCT	Seniors Programs Public Health Nurses	Seniors	Urban- rural community
Blackford,^Citation36	USA	Provide an educational resource about vaccinations, particularly regarding misconceptions and concerns, for school nurses, parents, and children	Qualitative	School Nurses	Children	School
Bowling^Citation37	USA	Understand the role that nursing intervention have to enhance vaccination rates (historical aspects as well as present day information)	Review	Pediatric Nurses	General Population	Primary Care
Brackett et al.,^Citation38	USA	Investigate whether the use of MI in the community pharmacy improves immunization readiness and rates for hepatitis B, hepatitis A/B combination, herpes zoster, pneumococcal, and tetanus–diphtheria–acellular pertussis immunizations.	Cross- sectional	Pharmacists	Community Members	Grocery Store Pharmacy
Carhart et al.,^Citation39	USA	Understand the reasoning behind low-uptake of the HPV vaccine in the state of Virginia	Qualitative	Nurses (Stakeholder Nurses in Cancer prevention)	Adolescents	NR
Courtney^Citation40	Canada	Address the Problem of Practice (PoP), what training is needed to ensure HCPs are capable to communicate effectively with vaccine-hesitant patients	Organizational improvement plan	Public Health Nurses	NR	Public Health Units
D’Arrigo^Citation41	USA	Understand the impacts of the Mumps outbreak in Hawaii and figure out what can be done to better understand vaccine hesitancy in parents and find clear ways to address this at the pharmacy	Informative/ Descriptive	Pharmacists	NR	Pharmacies
Dahlqvist et al.,^Citation42	Sweden	Describe how nurses in child health centers deal with parents who are hesitant to child vaccinations.	Qualitative	Child Health Nurses	Children	Hospitals, Child Health Centers
Davis et al.,^Citation43	USA	Determine whether an intervention similar to the private office-based intervention, but tailored to PHNs and with the addition of an immunization booklet designed for parents, could improve vaccine risk/benefit communication in a timely manner among PHNs	Pre- Post Design	Public Health Nurses	Children	Primary Care
Deem^Citation44	USA	Discuss the ethical questions that arise when a parent refuses some or all recommended childhood vaccines for nonmedical reasons, and discuss ways in which nurses and other HCP can respond ethically and effectively to vaccine refusal	Descriptive	Nurses	Children	Primary Care
Dempsey & Zimet^Citation45	USA	Describe a selection of recent intervention studies for increasing adolescent vaccination.	Review	Nurses	Adolescents	Varies
Donavan & Bedford^Citation46	United Kingdom	Analyze and inform on current common questions parents ask about immunization in the United Kingdom.	Descriptive	Primary Care Nurses	Children	Primary Care
Dubé et al.^Citation47	Canada	Understand the determinants of low HPV vaccine uptake and identify strategies to enhance vaccine acceptance using the socio-ecological model.	Qualitative	School Nurses	School aged children	Schools
Dubé et al.,^Citation48	Canada	Describe good practices in developing communication materials to address vaccine hesitancy	Inventory Assessment/Analysis	Nurse Practitioners	General Population	Virtual assessments
Fernbach^Citation49	USA	Discuss the ethical dilemma that a primary care NP must face when parents refuse to have their children immunized.	Review	Primary Care Nurse Practitioners	Children	Primary Healthcare
Fogarty et al.,^Citation50	USA	Disseminate what works in their practice (we have developed a team-based routine that has improved our efficiency and effectiveness in getting our patients vaccinated)	NR	Licensed Practical Nurse	General Population	Primary Care
Gagneur et al.^Citation1	Canada	Develop and validate immunization-specific MI training for immunization nurses.	Pre- post test	Immunization Nurses	Children	Community clinics
Greene^Citation51	USA	Discuss some of the latest findings on vaccination and suggest responses that school nurses can use to reassure parents	Informative	School Nurses	School aged children	Schools
Hidalgo^Citation52	USA	Increase Gardasil 9 rates in a small, rural school-based health center	Plan-Do-Study-Act quality-improvement model	Doctorate of Nursing Student	School aged children	Rural school- based health clinic
Hinman^Citation53	USA	A tool to think about carefully developed and forthright responses to immunization and helping people make truly informed immunization decisions	Informative	Nurses	NR	Cases across U.S. and Canada
Hoekstra et al.^Citation54	USA	Reinforce the unique skills that nurses bring to what must be interdisciplinary approaches in the persistent struggle to address vaccine hesitancy.	Commentary	Nurses	Children	Any clinical setting
Holland Wade^Citation55	USA	Address issues associated with refusal to immunize children and how nurses can influence immunization decisions.	Review	Nurses	Children	Primary Care
Hurley-Kim^Citation56	USA	Review strategies pharmacists can use to reduce the burden of vaccine hesitancy	Informative/ Descriptive	Pharmacists	NR	NR
Kenney et al.,^Citation57	USA	Inform pharmacists on how to counter vaccine hesitancy in parents and the general population	Descriptive	Pharmacists	NR	NR
Koslap-Petraco et al.,^Citation58	USA	Educate nurses on communicating the benefits of combination vaccines to parents and other healthcare providers.	Descriptive	Nurses	Children and Infants	Primary Care
Koslap-Petraco^Citation59	USA	Review the history of vaccine hesitancy and discuss a successful paradigm for speaking with vaccine-hesitant parents	Review	Nurse Practitioners	NR	NR
Kubin^Citation60	USA	Review the current literature regarding U.S. vaccine compliance data and the three VPD with continued prevalent outbreaks. Literature regarding influencing factors leading to outbreaks, changes in vaccination practices, and how nurses can best intervene will also be discussed.	Review	Nurses	NR	NR
Lisenby et al.,^Citation61	USA	Help pharmacists provide evidence-based facts and education to address common misconception and influence the anti-vaccination movement	Informative	Pharmacists	NR	Community and ambulatory settings
Ludwikowska et al.^Citation62	Poland	An analysis of the structure of the Prophylaxis Program against HPV in Wroclaw, Poland, (afterward – the Program) as well as on the attitudes to the HPV vaccination among its participants: parents, 13-year-old girls and the nurses who administer the vaccination.	Program evaluation	Nurses	Teenage Girls	GP offices
Luthy et al.,^Citation63	USA	Review evidence-based answers to common parental questions regarding childhood vaccinations.	Integrative literature review	School Nurses	School aged children	Schools
MacDonald & Wick^Citation64	USA	Provide a comprehensive understanding of such influences can help pharmacists and pharmacy technicians identify and communicate with hesitant individuals better	Educational Resource	Pharmacists and pharmacy technicians	Infants and Children	Pharmacies
Maurici et al.,^Citation65	Italy	Assess the impact of a three-day residential course concerning empathy and counseling abilities on patients’ ratings of the level of empathy of physicians and nurses working in vaccination centers.	Pre- post Design	Nurses	NR	Local Health Units
Marcus^Citation66	USA	Useful tips to address vaccine hesitancy through effective communication and evidence-based answers to common and uncommon vaccine myths for communities and discuss	Program Evaluation Paper	Nurses	Vulnerable communities	Orthodox Jewish Community
Mossey et al.,^Citation67	Canada	Understand parents’ and nurses’ experiences of decision-making about childhood immunization, specifically measles-mumps-rubella and/or diphtheria-tetanus-acellular pertussis.	Interpretative description	Primary Care or Public Health Nurses	Children	Small Urban centers
Navin et al.,^Citation68	USA	Understand the dispositions of the public health staff who provide “waiver education”	Descriptive	Public Health Nurses	Daycare and school-aged children	Local Health departments
Nicastro et al.,^Citation69	USA	Discuss the scope of the problem (parental rejection of vaccines for their children), explore the parental decision-making process regarding vaccines for their children, and consider the implications for nurse practitioners with regard to increasing vaccination uptake rates among their patients	Informative/ Descriptive	Nurse Practitioners	Children	NR
Nold et al.,^Citation70	USA	Describes the development and integration of the simulation experience, its aims and outcome measures, and students’ evaluations of the experience.	Qualitative	Nursing Students	A simulation of a parent (infant child)	Nursing school (clinical simulation)
NR^Citation71	Varied	Review of the unmet vaccine needs for high-risk populations, detailed targeted approaches to improving immunization rates in high-risk populations, shared insights on developing collaborations, and outlined strategies for developing partnerships and overcoming challenges.	Ask the Expert	Pharmacists	High- Risk population	Pharmacies
Nutty^Citation72	USA	Discussion about the responsibility of healthcare professionals to educate anti- vaccinators and lay their fear to rest.	Informative	Nurses	Children	NR
O’Keefe et al.^Citation73	USA	Inform nurses about important facts about vaccines and what populations are crucial for vaccination.	Informative (Textbook chapter)	Nurses	NR	All Healthcare settings
Omecene et al.^Citation74	USA	Discuss the implementation of the PPAG position paper recommendations, including key barriers in outpatient settings and potential strategies to successfully incorporate the recommendations into practice.	Position paper	Pharmacists	Children	Outpatient clinic/ pharmacy
Orenstein et al.^Citation75	USA	Examine the factors that affect vaccine confidence	Informative/ Descriptive	Nurses	Children	Varied
Poudel et al.^Citation76	Australia	Review the barriers and challenges to vaccination with a focus on the role of pharmacists as vaccinators, and the challenges associated with effective implementation of pharmacist administered vaccination services	Qualitative	Pharmacists	NR	Community pharmacies
Pullagura et al.^Citation77	Canada	Understand community pharmacists’ attitudes toward, and experiences with, influenza VH, and explore factors impacting their engagement with patients on the influenza vaccine.	Qualitative	Pharmacists	General Population	Community pharmacies
Punch^Citation78	Canada	Understand what worked/ happened to Oxford county with 2 outbreaks in 2003 and 2008	Case Study	Nurses	Children	Orthodox Jewish Community
Queeno^Citation79	USA	Detail the implementation of a pharmacist-driven education program targeting patients who originally declined pneumococcal or influenza vaccination upon hospital admission and to evaluate the results.	Pre-post Design	Pharmacists	Patients admitted to hospital	Hospitals
Rawson et al.^Citation80	USA	Provide valuable information for pharmacists and pharmacies to reference when con-fronting vaccine hesitancy.	Informative (update on best practices)	Pharmacists	NR	NR
Rivera^Citation81	USA	Develop a clinical practice guideline with recommendations for vaccination and vaccine hesitancy in the pediatric setting.	Clinical Practice Guideline Development	Pediatric Nurses	Children	Pediatric Primary Care
Schollin Ask et al.^Citation82	Sweden	Identify why parents refused to let their infant have the vaccination or were unsure	Cross- sectional	Child Health Nurses	Infants	Child Health Center
Scott & Batty^Citation83	Canada	Investigate factors related to HPV vaccine uptake in Canada. An overview of the disease, vaccinations, emerging issues, and the role of a PCP, specifically NP’s.	Review	Nurse Practitioners	NR	Schools
Sharpe et al.,^Citation84	USA	Discuss strategies to respond to individuals who are vaccine hesitant	Informative/ Descriptive	Pharmacists	Children	Community pharmacies
Speck et al.,^Citation85	USA	Identify interventions healthcare providers can use to acknowledge and address parents who are vaccine- hesitant	Review	Childcare Nurses	Children	Primary Care, hospitals
Stevens^Citation86	USA	Assess the effects of a C.A.S.E. Approach learning module on family nurse practitioner students’ perceived levels of knowledge and self-efficacy regarding vaccination discussion with vaccine hesitant parents	Pre- post design	Family Nurse Practitioner Students	NR	University
Stinchfield^Citation87	USA	Provide research-based answers to practice questions submitted by JSPN readers.	Ask the expert	Pediatric Nurses & NPs	NR	Varies
Taddio et al.^Citation88	Canada	Document acceptability of key tools included in the multifaceted KT intervention and their effectiveness in improving knowledge and attitudes about vaccination pain and fear	Mixed methods	Immunization, School & Charge Nurses	Grade 7 students	School
Venzke et al.^Citation89	USA	Evaluate an online, interactive, learning module to enhance knowledge of nurse practitioner students on vaccine hesitancy and refusal issues and examine the effectiveness of the learning module on enhancing nurse practitioner student knowledge of MI communication skills to address issues of vaccine hesitancy and refusal	Pre- post design	NP students	NR	University
Violette et al.,^Citation90	Canada	Educate pharmacists about way to communicate people who may be vaccine hesitant	Commentary	Pharmacists	NR	Community pharmacies
Vyas et al.,^Citation91	USA	Determine the impact of a vaccine hesitancy learning unit on student knowledge, attitudes, and ability to address vaccine hesitancy and/or refusal.	Pre-Post Design	Pharmacy Students	NR	University
Warner^Citation92	England	Explore the external and internal influences related to the uptake of flu vaccination with regard to both healthcare workers and their patients and discuss the ways in which nurses can help patients eligible for free flu vaccinations to make informed choices.	Informative	Nurses	General Population	NR
Ziemczonek^Citation93	Canada	Discuss approaches the author found worked in their practice to address vaccine hesitancy	Case Study	Pharmacists	NR	Pharmacies

Abbreviations: RCT: Randomized Control Trial, HPV: Human Papilloma Virus, MI: Motivational Interviewing, HCP: Health-Care Practitioner, PHN: Public Health Nurse, NP: Nurse Practitioner, VPD: Vaccine Preventable Disease, PPAG: Pediatric Pharmacy Advocacy Group, VH: Vaccine hesitancy, PCP: Primary Care Provider, C.A.S.E: Corroborate, About Me, Explain/Advise, JSPN: Journal for Specialist in Pediatric Nursing, KT: Knowledge Translation.

Figure 2. PRISMA flow chart.

Barriers for nurses and pharmacists to address vaccine hesitancy

We identified nine themes related to barriers for nurses and pharmacists to address vaccine hesitancy among patients, parents, or the public. Reported barriers and corresponding COM-B Model of Behavior mapping are outlined in Table 2. The most commonly reported barrier for both nurses and pharmacists was that patients and/or parents were misinformed about vaccinations (n = 29 nursing focused papers and n = 6 pharmacy focused papers). In both nursing and pharmacy focused papers, the next two most commonly reported barriers were the lack of communication aid/guidance (n = 18, n = 4, respectively) and addressing patient mistrust in the system (n = 10, n = 5, respectively).

Table 2. Reported barriers to addressing vaccine hesitancy

COM-B	COM-B Sub-component	Barrier	Nurse source(s)	Pharmacist source(s)
Capability
	Psychological	Lack of understanding of vaccine hesitancy	Anderson,^Citation30 Gagneur,^Citation94 Venzke,^Citation89 O’Keefe,^Citation73 Fogarty^Citation50 (n = 5)	Queeno,^Citation79 Pullagura,^Citation77 Poudel,^Citation76 Violette^Citation90 (n = 4)
Capability & Opportunity	Psychological, social & physical	Lack of communication aids and guidance	Anderson,^Citation30 Marcus,^Citation66 Berry,^Citation34 Stevens,^Citation86 Dube (2020), Rivera,^Citation81 Venzke,^Citation89 O’Keefe,^Citation73 Dube (2019), Hidalgo,^Citation52 Orenstein,^Citation75 Nold,^Citation70 Bowling,^Citation37 Navin,^Citation68 Hinman,^Citation53 Koslap- Petraco,^Citation59 Punch,^Citation78 Kubin^Citation60 (n = 18)	Sharpe,^Citation84 Pullagura^Citation77Deepti Vyas,^Citation91 MacDonald^Citation64 (n = 4)
		Healthcare provider- patient relationship	Mossey,^Citation67 Maurici,^Citation65 Deem,^Citation44 Courtney^Citation40 (n = 4)	Brackett^Citation38 (n = 1)
		Lack of time to address vaccine hesitancy	Berry,^Citation34 Hinman,^Citation53 O’Keefe,^Citation73 Hoekstra,^Citation54 Dube (2019), Stinchfield,^Citation87 Carhart^Citation39 (n = 7)	N/A
Opportunity
	Social & physical	Lack of opportunities to discuss vaccine hesitancy	Scott,^Citation83 Gagneur,^Citation94 Warner,^Citation92 Hidalgo,^Citation52 Carhart^Citation39 (n = 5)	N/A
		Health-care provider collaboration	Davis,^Citation43 Hidalgo,^Citation52 Orenstein^Citation75 (n = 3)	Brackett,^Citation38 NR^Citation71 (n = 2)
Opportunity & Motivation	Social, physical, automatic & reflective	Patients are misinformed about vaccinations	Black,^Citation35 Greene,^Citation51 Luthy,^Citation63 Speck,^Citation85 Scott,^Citation83 Mossey,^Citation67 Schollin (2019), Warner,^Citation92 Anderson,^Citation31 Blackford,^Citation36 Davis,^Citation43 Hinman,^Citation53 Koslap- Petraco,^Citation58 Nold,^Citation70 Koslap- Petraco,^Citation59 Ludwikowska,^Citation62 O’Keefe,^Citation73 Franklin,^Citation32 Nicastro,^Citation69 Dahlqvist,^Citation42 Fogarty,^Citation50 Dube (2019), Stinchfield,^Citation87 Carhart,^Citation39 Kubin,^Citation60 Holland Wade,^Citation55 Hidalgo,^Citation52 Bernard,^Citation33 Fernbach (2010) (n = 29)	Lisenby,^Citation61 Sharpe,^Citation84 Kenny (2019), Poudel,^Citation76 Hurley- Kim,^Citation56 D’Arrigo^Citation41 (n = 6)
		Patients have a mistrust in the system	Donavan,^Citation46 Marcus,^Citation66 Berry,^Citation34 Navin,^Citation68 Blackford,^Citation36 Nutty,^Citation72 Hoekstra,^Citation54 Bowling,^Citation37 Carhart,^Citation39 Orenstein^Citation75 (n = 10)	American Pharmacist Association (2020), Sharpe,^Citation84 Kenny (2019), Rawson,^Citation80 D’Arrigo^Citation41 (n = 5)
		Influence of social media	Mossey,^Citation67 Koslap- Petraco,^Citation58 Koslap- Petraco,^Citation59 Dahlqvist,^Citation42 Fogarty,^Citation50 Dube (2019), Fernback (2011), Orenstein^Citation75 (n = 8)	MacDonald,^Citation64 Kenny (2019), Hurley- Kim^Citation56 (n = 3)

Capability

Lack of understanding of vaccine hesitancy. A key barrier was a lack of provider understanding of the definition of vaccine hesitancy. The papers described provider confusion on the differences between vaccine hesitancy and anti-vaccination.

Capability and opportunity

Lack of communication aids and guidelines

A common barrier for nurses and pharmacists was the lack of communication aids (i.e., posters, pamphlets, and brochures) and guidelines for providers to reference and support the conversation with vaccine hesitant patients. Studies reported no clear guidelines for providers to communicate effectively with vaccine hesitant patients and/or parents as most resources focused on the evidence about the effectiveness and safety of vaccines and not strategies to address hesitancy.

Health-care provider–patient relationship

A key barrier identified was the relationship nurses and pharmacists had with their patients. Patients felt like they were unable to discuss their concerns with health-care providers, due to fear of dismissal and judgment. Further, studies reported that if there was a lack of trust between patients and health-care providers, nurses and pharmacists lacked the ability/confidence to discuss sensitive subjects, such as fear of vaccines.

Lack of time to address vaccine hesitancy

Nurses reported having limited time to address vaccine hesitancy with their patients. Studies described that other health issues were often prioritized and/or appointment times were limited to one or two topics. Pharmacists did not report time constraints as a barrier to addressing vaccine hesitancy in the included studies.

Opportunity

Lack of opportunities to discuss vaccine hesitancy

Nursing-related studies identified a lack of nurse–patient interactions to discuss vaccine hesitancy. Studies reported that there was not always an opportunity to facilitate this discussion, especially if patients were healthy and not presenting to the clinic. As a result, patients were often not given the opportunity to express their vaccine concerns with a trusted health-care provider.

Health-care provider collaboration

Studies reported that nurses and pharmacists identified a lack of health-care provider collaboration, among nurses, pharmacists, physicians, and public health, when addressing vaccine hesitancy as a key barrier to success.

Opportunity and motivation

Patients are misinformed about vaccinations

A common barrier identified by both nurses and pharmacists was difficulty in addressing patients’ hesitancy that resulted from the patient being misinformed about vaccines. Patients and/or parents often present to appointments with emotional anecdotal stories that include nonscientific information, that counter the known facts about vaccine effectiveness. It is challenging for nurses and pharmacists to counter misinformation that is highly emotional.

Patients have a mistrust in the system

A key barrier for nurses and pharmacists to address vaccine hesitancy was patients having a mistrust in the health-care system and individual providers finding it hard to regain that trust. Patients in several studies reported a lack of trust in government and the health-care system. Nurses and pharmacists identified significant barriers in overcoming patients’ mistrust in the health-care system as discussing patients’ mistrust in government does not fall under the “job description” or is seen as more of a public health issue.

Influence of social media

Several studies described the role of social media on nurses’ and pharmacists’ ability to address vaccine hesitancy. Patients are significantly influenced by what they consume via social media. As a result, nurses and pharmacists reported feeling helpless when attempting to address misconceptions and myths about vaccines.

Enablers for nurses and pharmacists to address vaccine hesitancy

We identified six themes related to enablers for nurses and pharmacists to address vaccine hesitancy among patients, parents, or the public. Reported enablers and corresponding COM-B Model of Behavior mapping is outlined in Table 3. In both nursing and pharmacy focused studies, the most commonly reported enablers were the availability and dissemination of resources to support education (n = 29 nursing focused papers, and n = 7 pharmacy focused papers) and health-care provider–patient relationship (n = 25 and n = 6, respectively).

Table 3. Reported enablers to addressing vaccine hesitancy

COM-B	COM-B sub-component	Enabler	Nurse source(s)	Pharmacist source(s)
Capability & Opportunity	Psychological, social & physical	Availability and dissemination of resources to support education	Luthy,^Citation63 Speck,^Citation85 Scott,^Citation83 Marcus,^Citation66 Mossey,^Citation67 Anderson,^Citation31 Davis,^Citation43 Dube (2020), Nutty,^Citation72 Rivera,^Citation81 Venzke,^Citation89  Franklin Apfel,^Citation32 Nicastro,^Citation69 Greene,^Citation51 Gagneur,^Citation94 Stevens,^Citation86 Blackford,^Citation36 Nold,^Citation70 Taddio,^Citation88 Ludwikowska,^Citation62 Dahlqvist,^Citation42 Deem,^Citation44 Hidalgo,^Citation52 Fernback (2011), Courtney^Citation40 (n = 25)	Lisenby,^Citation61 Deepti Vyas,^Citation91 Queeno,^Citation79 Rawson,^Citation80 Hurley- Kim,^Citation56 D’Arrigo,^Citation41 Ziemczonek^Citation93 (n = 7)
Opportunity	Social & physical	Reminder systems for health-care providers	Anderson,^Citation30 Amanda (2015), Carhart,^Citation39 Bernard^Citation33 (n = 4)	N/A
Opportunity & Motivation	Social, physical, automatic & reflective	Health-care provider–patient relationship	Donavan,^Citation46 Speck,^Citation85 Scott,^Citation83 Berry,^Citation34 Mossey,^Citation67 Stevens,^Citation86 Navin,^Citation68 Warner,^Citation92 Blackford,^Citation36 Hinman,^Citation53 Maurici,^Citation65 Nutty,^Citation72 Venzke,^Citation89 Koslap- Petraco,^Citation59 O’Keefe,^Citation73 Hoekstra (2013), Punch,^Citation78 Nicastro,^Citation69 Dahlqvist,^Citation42 Dube (2019), Stinchfield,^Citation87 Kubin,^Citation60 Deem,^Citation44 Fernbach,^Citation49 Orenstein^Citation75 (n = 25)	MacDonald,^Citation64 Brackett,^Citation38 Pullagura,^Citation77 Poudel,^Citation76 D’Arrigo,^Citation41 Ziemczonek^Citation93 (n = 6)
		Agreement on a revised schedule	Navin,^Citation68 Bowling^Citation37 (n = 2)	N/A
		Collaborative practice to support vaccine acceptance	Marcus,^Citation66 Fogarty,^Citation50 Dube (2019), Carhart,^Citation39 Bernard,^Citation33 Orenstein^Citation75 (n = 6)	NR,^Citation71 Poudel,^Citation76 Omecene^Citation74 (n = 3)
Motivation	Automatic & reflective	Health-care provider’s identity and role in addressing vaccine hesitancy	Speck,^Citation85 Berry,^Citation34 Scholin Ask,^Citation82 Stevens,^Citation86 O’Keefe,^Citation73 Dube (2019), Bernard,^Citation33 Courtney^Citation40 (n = 8)	N/A

Capability and opportunity

Availability and dissemination of resources to support education

Nurses and pharmacists expressed the need to educate their patients to help shift patients from hesitant to acceptant. Studies described easy access of information to give to patients and health-care providers as an important enabler to addressing vaccine hesitancy. Nurses and pharmacists can use these accessible resources (e.g., pamphlets and posters) to facilitate a conversation on vaccine hesitancy, educate patients on vaccines, and support informed decision-making.

Opportunity

Reminder system for health-care providers

Nurses described a key enabler to be a reminder system to discuss vaccinations during visits prior to scheduled vaccination appointments. In doing so, nurses were able to provide resources to patients and parents and have time to discuss concerns.

Opportunity and motivation

Health-care provider–patient relationship

Nurses and pharmacists noted the importance of having a strong relationship with their patients to help build trust to discuss vaccines in an effective manner. This was particularly relevant in the primary care and school settings. Nurses and pharmacists also noted that the time they were able to give to patients helped establish this trust to a greater extent.

Agreement on a revised schedule

For patients with higher levels of vaccine hesitancy, nurses found it beneficial to formulate an agreed upon vaccination schedule so there was not as many vaccinations given at once, or were more spaced out, it is crucial that this is well-documented among all health-care providers. This approach ensures that vaccinations are still administered, and patients feel involved in the vaccination process. This was not reported as an enabler for pharmacists.

Collaborative practice to support vaccine acceptance

Nurses and pharmacists noted the importance of interprofessional collaboration to address vaccine hesitancy. This included collaborating with physicians, public health, and other health-care professionals to create a clear and consistent message to support vaccine uptake.

Motivation

Health-care providers identity and role in addressing vaccine hesitancy

Nurses noted that their role and identity as nurses helped them to form strong relationships with their patients. Studies described the professional identity as a motivator for addressing vaccine hesitancy and facilitating the uptake of vaccinations.

Interventions for nurses and pharmacists to address vaccine hesitancy

In this review, 58 out of the 66 records reported strategies or interventions to facilitate nurses or pharmacists to address vaccine hesitancy. We characterized the reported interventions using the BCW’s intervention function categories. The frequency of BCW intervention functions include: Education (n = 47), Training (n = 26), Persuasion (n = 16), Enablement (n = 8), Environmental Restructuring (n = 3), and Modeling (n = 2). As shown in Table 4, interventions were multicomponent and consisted of a variety of different combinations of BCW intervention functions. Most commonly, Education and Training together comprised 16 different interventions. Table 4 describes examples of reported interventions in the following four categories: 1) Communication tools/guidelines to educate patients, 2) Strategies for open communication with patients, 3) Educational workshops, and 4) Social Support.

Table 4. Reported interventions and corresponding intervention functions

Type of intervention	Description of interventions	BCW intervention function	Nursing	Pharmacy
Communication Tools/ Guidelines to Educate patients	Educational sessions to teach nurses how to discuss vaccine hesitancy with patients and/ or parents	Education, persuasion	Anderson,^Citation30 Berry,^Citation34 Schollin Ask,^Citation82
	Physical tools to give to patients and/or parent (e.g., Pamphlets. magazines, workshops for patients, toolkits)	Education	Donavan,^Citation46 Scott,^Citation83 Speck,^Citation85 Marcus,^Citation66 Stevens,^Citation86 Anderson,^Citation31 Davis^Citation43	Lisenby^Citation61
	Teach nurses/ pharmacists about how to talk about alternatives to the typical plan (e.g., combination vaccines, agreeing upon a revised schedule)	Education, Training	Koslap- Petraco,^Citation58 Rivera,^Citation81 Holland Wade^Citation55	Kenny (2019)
Strategies for Open Communication with Patients	Identify ways to openly communicate with patients and/ or parents and ensure that they are making an informed decision and/or informed consent (e.g., C.A.S.E. approach, allowing patients to make informed decisions, understanding of vaccine hesitancy as a continuum)	Education	Black,^Citation35 Greene,^Citation51 Speck,^Citation85 Navin,^Citation68 Warner,^Citation92 Blackford,^Citation36 Ludwikowska,^Citation62 Kubin^Citation60	Ziemczonek^Citation93
	Imploring a culturally sensitive dialogue with people who are opposed to vaccine because of religion or culture reasons	Enablement	Marcus,^Citation66 Punch^Citation78
	Focus on including parents in the dialogue as opposed to talking at them (e.g., Familiarizing patients with nurses to build trustworthiness, educational sessions with parents)	Education, Persuasion	Mossey,^Citation67 Stevens,^Citation86 Schollin Ask,^Citation82 Holland Wade^Citation55	MacDonald,^Citation64 Violette^Citation90
	Therapeutic communication strategies for providers (e.g., identify factors for why someone might be hesitant and try to understand those decisions, call parents personally to discuss vaccination plan before appointments)	Enablement, Persuasion	Hoekstra,^Citation54 Deem,^Citation44 Hidalgo,^Citation52 Bernard^Citation33	D’Arrigo^Citation41
	Tell personal stories about vaccination experience, from nurse and pharmacist perspective	Modeling, education	Fogarty^Citation50	American Pharmacists Association^Citation29
Workshops	Training workshops on how to communicate effectively with patients and/ or parents, simulation in school settings (e.g., simulation training with students, workshops on tips and tricks to communicate with vaccine hesitant individuals)	Education, Training	Dube (2020), Maurici,^Citation65 Nold,^Citation70 Nutty,^Citation72 Venzke,^Citation89 Fernback (2011), Orenstein^Citation75	Deepti Vyas,^Citation91 Brackett^Citation38
	Provide multiple strategies for health-care providers to choose from (e.g., motivational interviewing techniques, C.A.S.E approach)	Education+ Enablement+ Training	Gagneur,^Citation94 Speck,^Citation85 Marcus,^Citation66 Mossey (2019), Stevens,^Citation86 Navin,^Citation68 Davis^Citation43
	Teach providers how to have empathetic and effective discussions with patients and/ or parents (e.g., having a communication plan, advanced nurses aiding in this process)	Education + Training + Persuasion	Koslap- Petraco,^Citation59 O’Keefe,^Citation73 Courtney,^Citation40 Warner^Citation92	Queeno,^Citation79 Rawson^Citation80
Social Support	Nurse managers available to help nurses address vaccine hesitancy	Environmental restructuring	Apfel^Citation32

Discussion

Summary of evidence

This scoping review aimed to identify, characterize, and map the existing knowledge on a) nurses’ and pharmacists’ perceived barriers and enablers to addressing vaccine hesitancy among patients and b) strategies or interventions for nurses and pharmacists to address vaccine hesitancy in their practice. We identified 66 records that described barriers and enablers for nurses and pharmacists to address vaccine hesitancy in practice and existing strategies/interventions that nurses and pharmacists use to address vaccine hesitancy with their patients. In this review, we mapped the reported barriers and enablers to addressing vaccine hesitancy onto the COM-B Model of Behavior and interventions onto the BCW’s intervention functions. These frameworks enabled a comprehensive behavioral analysis of nurses’ and pharmacists’ capability, opportunity, and motivation to address vaccine hesitancy among their patients. Reported barriers included a lack of understanding of vaccine hesitancy (capability), provider–patient relationship (opportunity), and patients being misinformed about vaccines (motivation). Reported enablers included having availability of resources to support education (capability), open communication with patients and/or parents (opportunity), and having a collaborative practice to support vaccine acceptance (opportunity, motivation). Interventions ranged from creating a more inclusive environment to educating providers on how to talk to vaccine hesitant patients. Based on this behavioral analysis, future research can use our findings to select and tailor interventions to address the behavioral determinants related to vaccine hesitancy for a range of immunization programs, including COVID-19 vaccines.

Capability

Our findings highlight the influence of nurses’ and pharmacists’ capabilities on addressing vaccine hesitancy. According to the BCW, capability is defined as an individual’s psychological and physical ability to engage in a behavior of interest (i.e., addressing vaccine hesitancy).²⁷ This scoping review identified several barriers and enablers related to nurses’ and pharmacists’ psychological and physical skills to address vaccine hesitancy.

First, included studies reported that nurses and pharmacists had a lack of understanding of vaccine hesitancy. Previous research highlights that most health-care providers do not receive training on vaccine hesitancy.^11,77,95,96 The majority of interventions identified in this scoping review included an education and/or training intervention function (n = 73), including communication aids, guides, and tools to support nurses and pharmacists to address vaccine hesitancy.^{31,43,46,61,66,83,85,97} According to the BCW, these types of educational interventions are effective at addressing capability-related barriers,¹⁸ including nurses’ and pharmacists’ lack of understanding of vaccine hesitancy and patients’ misinformation on vaccinations. However, despite the availability of these interventions, our review identified that barriers still hinder their utility in practice. Improved implementation efforts of education and training components are needed to support the use of vaccine hesitancy communication aids and tools in nursing and pharmacy practice. For example, previous research has shown simulation training to be an effective mechanism for health-care provider students to develop their knowledge, skills, attitudes, and beliefs related to vaccination practice.^91,98 Previous work has been conducted with medical students to develop simulation interventions to address vaccine hesitancy;⁹⁹ however, there is limited evidence on the use of simulation with vaccine hesitancy or the necessary components needed for nursing and pharmacy students.^91,100 Future research might benefit from further development of vaccine hesitancy educational interventions for nursing and pharmacy students.

Opportunity & motivation

Intersecting barriers and enablers within opportunity and motivation appear to play the most impactful role on nurses’ and pharmacists’ ability to address vaccine hesitancy. Opportunity refers to social and environmental factors external to an individual that either positively or negatively facilitate or prompt a particular behavior,²⁷ whereas motivation is defined as the brain processes that enact or inhibit behavior.²⁷ In this review, the literature highlighted the critical role of a trusting patient–health-care provider relationship on vaccine acceptance. Previous research has identified nurses and pharmacists as trusted health-care providers as they are uniquely situated within the health-care system to have discussions with patients about health concerns.¹⁰¹ However, despite the trustworthiness of nurses and pharmacists, this review identified several barriers related to external social influence on patients, including their mistrust in the health-care system, misinformation about vaccines, and the impact of social media on vaccine hesitancy. With patients having unlimited access to information via the internet, providers may find it challenging to address concerns from anti-vaccination groups or anecdotal stories from friends and families. Previous research refers to the “informed opposition” patients, in which individuals have done excessive research on poor outcomes related to vaccines.^53,102,103 These social influences make it challenging for nurses and pharmacists to develop a trusting relationship and effectively address vaccine hesitancy with their patients. Contrarily, as this review identified, nurses and pharmacists can use their own social influence as an enabler to positively affect change. There are opportunities to leverage known trust and credibility among nurses and pharmacists as a facilitator to promote vaccine acceptance.

Although we identified many education and training interventions, fewer interventions exist for opportunity- and motivation-related barriers and enablers, including patients’ mistrust and the influence of social media. With the BCW intervention function mapping, we identified only 16 persuasion interventions and eight enablement interventions. Previous behavioral science research has shown that persuasion and enablement-type interventions are effective at addressing behavioral determinants related to opportunity and motivation.¹⁸ In the vaccine hesitancy context, persuasion and enablement interventions include providers maintaining an open dialogue with patients by exploring what works best for them, sharing personal stories, humanizing or adding emotion to the information shared, using motivational interviewing techniques, or having an empathetic discussion.^{35,66,67,85,92} These types of behavioral interventions are urgently needed to combat vaccine hesitancy, especially given the current state of the COVID-19 pandemic. Although vaccine development, production, and distribution have been at the forefront of this pandemic, deployment efforts can be hampered by vaccine hesitancy. This will have significant impacts on achieving herd immunity and bringing the pandemic under control globally.¹⁰⁴ Social media movements, such as #ScienceUpFirst in Canada, have been developed to address the spread of COVID-19 misinformation online. This is a valuable example of a persuasion and enablement intervention that nurses and pharmacists can participate in to address COVID-19 vaccine hesitancy among the public.¹⁰⁵ In future intervention design work for COVID-19 vaccinations and other immunization programs, more broadly, tailored efforts are needed to include persuasion and enablement intervention functions, along with education and training strategies, to effectively target capability, opportunity, and motivation barriers to change.

Utility of the BCW in examining vaccine hesitancy

The BCW offers a systematic approach to understanding the range of factors influencing the target behavior (i.e., addressing vaccine hesitancy) and potential intervention options. By describing barriers and enablers in behavioral terms, this approach helps to identify what interventions are working and where there are gaps in aligning interventions to behavioral determinants. The implementation science literature has shown that interventions are more effective when theory is used to identify behavioral determinants and tailor interventions to address these factors.¹⁷ As described above, there are opportunities to use this theory-informed approach to tailor interventions to target nurses’ and pharmacists’ capability, opportunity, and motivation to address vaccine hesitancy among their patients. More recently, vaccination researchers have started to borrow from behavioral science to improve intervention design and implementation. The WHO Regional Office for Europe developed the Tailoring Immunization Programmes (TIP) approach to support vaccine uptake.¹⁰⁶ The TIP approach adapted the BCW for vaccine-related concerns and highlights the importance of understanding barriers to vaccination before developing interventions. Other researchers have been using the BCW to identify factors affecting influenza vaccine uptake in adults with chronic respiratory conditions¹⁰⁷ and health-care workers in long-term care facilities,¹⁰⁸ as well as designing an implementation intervention to increase HPV vaccinations in primary care.¹⁰⁹ We recommend building on this momentum and continuing to use behavioral science to design, implement, and evaluate interventions to address vaccine hesitancy.

Strength and limitations

This review posed several strengths, including the use of a rigorous JBI scoping review methodology, which included searching multiple databases and grey literature. Our selection, screening, extraction, and mapping steps were completed by two independent reviewers. Further, by applying the Behavior Change Wheel to our scoping review findings, we have clearly outlined behavioral determinants and mechanisms of action that can be tested to build our understanding of what interventions work in the context of addressing vaccine hesitancy. This work also presents the following limitations. First, we did not complete quality appraisal as the aim of this review was to map the existing literature. Second, although comprehensive, this scoping review was limited in the language and search terms used. As a result, our findings may be different from those conducted in lower-income and middle-income countries. Lastly, our review was conducted prior to the development of COVID-19 vaccinations and does not include COVID-19-specific vaccine hesitancy studies. However, our systematic, behavioral analysis provides a strong theoretical and empirical foundation, from which interventions can be designed to address COVID-19 vaccine hesitancy moving forward.

Conclusion

This current scoping review offers a detailed behavioral analysis of known barriers and enablers influencing nurses’ and pharmacists’ ability to address vaccine hesitancy and interventions mapped onto these behavioral determinants. We identified nine barriers and six enablers related to nurses’ and pharmacists’ capability, opportunity, and motivation to address vaccine hesitancy among their patients. The majority of existing interventions are focused on education and training, which target known capability-related barriers to addressing vaccine hesitancy. Fewer interventions exist to target known opportunity- and motivation-related barriers. Future vaccination practitioners and researchers can use these findings as a foundation to tailor interventions to target barriers and enablers to addressing vaccine hesitancy. Subsequent evaluation research is needed to understand if interventions are addressing the right behavioral determinants and to what effect.

Author contributors

All authors listed on the manuscript have met the ICMJE authorship criteria as follows: all authors (CC, JL, AS, BT, AS, NKK, HG, LS & JI) provided substantial contributions to the concept/design of the manuscript; helped draft, provided intellectual content and continual revision; provided final approval of the version to be published and are in agreement/accountable to all aspects of the work submitted.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.

Acknowledgments

The authors would like to thank Rachel Dorey and Lauren Donnelly for their help with data extraction.

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2021.1954444

Additional information

Funding

This study was funded by Dalhousie University’s Nursing Research & Development Fund