COVID-19 vaccinations and counselling: a mixed-methods survey of Australian general practice in July 2021

Keywords: COVID-19, delivery of health care, general practice, immunisation programmes, pandemic, primary health care, vaccinations, vaccine counselling.

The Australian COVID-19 immunisation program began in February 2021 with a planned five-phase rollout (Fig. 1). Phase 1a commenced on 22 February, with Comirnaty (Pfizer-BioNTech) delivered through state/territory vaccination centres and some residential aged care facilities. Phase 1b commenced on 22 March 2021, with Vaxzevria (AstraZeneca) offered through over 4500 community general practices (Kidd and de Toca 2021). From 5 July 2021, general practices were also able to offer immunisation with the Comirnaty vaccine (Kidd and de Toca 2021). Phase 2a commenced in May 2021, with the addition of community pharmacy sites offering COVID-19 vaccinations (Australian Government Department of Health 2021b). Phases 2b and 3 of the vaccine rollout commenced on 30 August 2021, when Comirnaty was made available to all people age 16 years and over (Prime Minister of Australia 2021). More than half of all COVID-19 vaccinations in Australia have been given in primary care settings (Royal Australian College of General Practitioners (RACGP) 2021a), with over 80% of these in general practice (Kidd and de Toca 2021).

Fig. 1.  COVID-19 vaccine national rollout strategy. Adapted from: Australian Government Department of Health (2021a).

Thrombosis with thrombocytopenia syndrome, a rare complication of Vaxzevria, was first reported in Australia on 2 April 2021 (Australian Technical Advisory Group on Immunisation (ATAGI) 2021a). This led to the first of many modifications to the vaccine rollout on 8 April, where Comirnaty became the ‘preferred’ vaccine for people under the age of 50 years (Australian Technical Advisory Group on Immunisation (ATAGI) 2021b). A subsequent revision included 50–59-year-olds in the cohort for whom Comirnaty was ‘preferred’ (Australian Technical Advisory Group on Immunisation (ATAGI) 2021b). Reports of thrombosis with thrombocytopenia syndrome and changes to the vaccination programme led to perceptions of vaccine hesitancy and vaccine preference within the Australian community (Lim and Nguyen 2021; Tsirtsakis 2021a). Willingness by the public to take up COVID-19 vaccines is essential to ensure successful rollout of vaccination programs and protection of the community (Danchin et al. 2020). Contemporaneous modelling (Hanly et al. 2021) showed that relatively high levels of vaccine hesitancy would delay reaching a target of 90% vaccine coverage by up to 4 months.

Anecdotal evidence suggested that vaccine counselling substantially added to GP workloads (Crimmins 2021; Royal Australian College of General Practitioners (RACGP) 2021a). A survey of Australian GPs conducted in the week prior to the vaccine rollout found that half (50.8%) considered asking for information about COVID-19 vaccines as a key issue for their patients (Copp et al. 2021). However, there were few published papers on GPs providing COVID-19 vaccine-specific counselling at the time of writing this paper (late 2021), and little is documented about the experiences of GPs in vaccine counselling in the context of the COVID-19 pandemic. We aimed to describe the experiences of Australian GPs who are counselling patients on COVID-19 vaccination and administering the vaccines, to better understand the impact on consultations and issues raised by or discussed with patients. This work is one part of a series of rapid surveys for policy impact that have been conducted throughout the pandemic.

We fielded an online survey of Australian community-based primary care practitioners from 7 to 15 July 2021 as part of a multi-country, repeating, mixed-methods survey of community-based primary care, assessing experiences during the COVID-19 pandemic. Each survey comprised two parts: a core set of questions, used in each iteration; and a set of questions used to explore a topic of timely interest. The core survey was developed in partnership with the Larry A Green Center (USA), the University of British Colombia (Canada), the University of Auckland (New Zealand) and the Australian National University (Australia).

Respondents included general practitioners, practice nurses and practice managers working in Australian general practice. The Royal Australian College of General Practitioners, Primary Health Networks and social media groups shared the survey URL. Respondents could sign up for alerts to be sent for each new survey. No compensation was offered for participation. Each survey was estimated to take 3–5 min to complete. A snowball method was used where participants were invited to share the survey with their general practice colleagues. Survey settings allowed only one completion per device.

Ethical approval was granted by the Australian National University Human Research Ethics Committee (2020/273). The research was undertaken with appropriate informed consent of participants.

This survey – series 15 of the Australian project – was divided into two sections. The first section sought information on how counselling relating to COVID-19 vaccination was impacting general practice consultations, and included multiple selection and open text responses. The questions in this section were developed by the investigators, based on their expertise in primary health care, review of up-to-date media and professional body reporting, and feedback from participants in earlier iterations of the survey. The survey questions were refined through iterative discussions among the investigators. Formal pilot testing of questions unique to this survey was not conducted due to time constraints.

The next section comprised the core, repeating part of the survey series. These questions were adapted from those developed by colleagues at the Larry A Green Center, and refined for the Australian context through discussions between the Australian and New Zealand investigators. These collected respondent characteristics including their role within the practice, practice postcode and practice features, and perceived strain experienced from COVID-19 infections and the vaccination program (rated on a 5-point Likert scale), and an open text ‘catch all’ type question where participants could expand on any issues they wished to highlight.

The series 15 questionnaire is included in Supplement 1.

Data were entered into Survey Monkey directly by respondents. Completion of the survey acted as implicit consent.

Quantitative analysis was conducted in SAS ver. 9.4. Frequencies and percentages were used to describe respondent and practice characteristics. The state/territory of the respondent was derived from the postcode. The estimated time spent counselling on vaccinations was calculated as mean and standard deviations. Due to small sample sizes, formal comparative statistics were not reported. Results for NSW were presented separately from other jurisdictions in places, as at the time this survey was fielded, NSW was experiencing a major COVID-19 outbreak, whereas other states and territories were not (Australian Government Department of Health 2021c).

An inductive content analysis approach was taken for coding open text responses about experiences with vaccine counselling in general practice (Kyngäs 2019). The open text responses were reviewed by two researchers (KOB and KB), and initial codes identified using keywords from each response. The codes were grouped into common themes based on the similarity and frequency of keywords, and relevance to our aim. Representative quotes were extracted for inclusion in this paper to describe each theme.

A total of 73 responses were received; 72 from general practitioners. All states/territories were represented, with 21 respondents (29%) from rural practices. Table 1 describes respondent and practice characteristics.

Table 1.  Respondent and practice characteristics.

A total of 23 out of 28 (82%) respondents in NSW reported high-to-severe strain, compared with 21 out of 45 (47%) in other jurisdictions. Fig. 2 shows that strain was high across all jurisdictions, with very few reporting low-to-no impact.

Fig. 2.  Strain on practice.

Table 2 shows which vaccines were being delivered at respondents’ practices. Most (65/73) were from practices offering COVID-19 vaccinations, with 64 (88%) offering Vaxzevria and 25 (34%) offering Comirnaty.

Table 2.  Practices offering vaccines and impact of vaccine counselling on consultations.

Table 2 also shows the impact of vaccine counselling on consultations. All respondents indicated that COVID-19 vaccination was discussed in at least some of their consultations, with 36 out of 73 (49%) reporting discussions took place in at least half of all consultations. On average, an additional 6 min (s.d. 2.9) was spent discussing COVID-19 vaccination in each consultation, with anywhere from 2 to 15 min being typical. This reflects additional time added on to usual consultations. The additional time spent on vaccine counselling in NSW was longer than in other jurisdictions (6.36 min vs 5.84 min).

A summary of patients’ concerns, as reported by our respondents, is shown in Table 3. A high proportion of respondents indicated patients had raised concerns about the safety of COVID-19 vaccines, and access to specific vaccines. Concerns that were more commonly raised with NSW respondents were access to COVID-19 vaccines, trust or credibility in information sources and concern about the efficacy of vaccines.

Table 3.  Patient concerns about COVID-19 vaccines, as reported by survey respondents.

Summary results for the whole survey are presented in Supplement 2.

All 73 respondents contributed comments about vaccine counselling and their experiences of vaccination in general practice. Four key themes were identified.

Nearly one-third of respondents reported strain on their general practice and administrative burden related to increased patient queries about vaccination, and managing practice logistics of vaccinations (e.g. staffing and fewer regular appointments).

‘It’s getting harder again with vax. We are short on doctors already. Now need to schedule extra clinics for vax. Lots of stress. Pressure on nurses and especially admin.’ – GP owner, regional SA

‘… admin team experiencing increased call numbers and increased verbal abuse’ – GP, regional NSW

Reported strain brought on by vaccinations has been in addition to long-term stress experienced across the pandemic, contributing to feelings of burnout.

‘It’s relentless, one challenge after another, with the usual lack of financial recognition and not taking holidays for those same financial reasons, yet desperately needing a break to fend off burnout’ – GP, urban VIC

‘As a GP, I’m totally burnt out and exhausted.’ – GP, regional QLD

Over half of respondents mentioned increased time pressures of having vaccine counselling added on to usual consultations, leading to longer consultations and decreased remuneration.

‘Adding to consultations often up to 5–10 min if people have a lot of questions. This is generally unpaid, as it is not on the day of vaccination and is absorbed into general consult.’ – GP, urban NSW

Some respondents expanded that the longer consultation time has flow-on effects impacting patient mood and increasing burden on reception staff.

‘Increased consult time means constantly running late. No breaks. Patients unhappy with extended wait times. Reception staff very tired and apologising often to patients. Longer consults mean less take home pay.’ – GP, urban Qld

Respondents articulated the burden of addressing patient concerns about COVID-19 vaccines, including anxiety about the safety and efficacy of all COVID-19 vaccines, and specific COVID-19 vaccines.

‘Some patients worried COVID vaccines are too ‘rushed’ and ‘experimental’’ – GP, urban SA

‘… Exhaustion of staff handling anxiety of patients about rare vaccine side effects that have not been well presented by state and federal health messaging.’ – GP, urban NSW

Respondents mentioned the constantly changing information caused confusion and created distress for clinicians and administration staff to keep up with changes to vaccine recommendations.

‘Vaccination rollout and the ever-changing rules is adding a lot of time pressure to nurse/admin and medical staff on top of our normal workload...’ – GP, urban Qld

‘The confusion created by federal and state differences in information has caused considerable distress to both clients and staff.’ – Practice Manager, regional NSW

Furthermore, respondents reported feeling ‘undermined’ by the delivery of vaccine information through public media rather than receiving information in advance, which would allow preparation for patient queries and expectations.

‘The vaccine rollout has been shambolic, the communication strategy has been poor, and GP information has been via mainstream media and announcements not flagged ahead of time.’ – GP, urban QLD

‘The most frustrating and difficult element of the vaccination rollout for us and our patients has been the regular, sometimes daily, changing of advice, often first reported through media before NSW Health advice has been received.’ – GP, urban NSW

Respondents perceived that communication from media and government sources had contributed to vaccine preferencing among patients, which compounded vaccine counselling challenges and clinician stress.

‘… We have the general population, politicians and even medical professionals labelling Pfizer as the ‘good’ vaccine and AstraZeneca as the ‘bad’ vaccine, despite the fact that both vaccines have a rare risk of serious adverse reactions. …’ – GP owner, regional NSW

‘Patients’ anxiety is driven by sensationalist tabloid style media reporting … So I am dealing with mental health consults re vaccination hesitancy, hysteria and trying to convey facts to patients. … ’ – GP, urban QLD

COVID-19 vaccine counselling is adding substantial time to general practice consultations (6 min on average), with discussion about the vaccines often being added onto unrelated consultations. Common topics of discussion include concern about the Vaxzevria vaccine, access to specific COVID-19 vaccines and concern about vaccine safety. In free-text responses, respondents linked longer vaccine-related consultation time with increased stress for all practice staff, with GPs running later than usual, having fewer breaks, and increased pressure on nursing and administrative staff.

Brief interventions and motivational interviewing are core skills utilised by GPs around preventative health and lifestyle issues requiring behaviour change by their patients (Royal Australian College of General Practitioners (RACGP) 2015). GPs assess patients’ readiness for change and respond appropriately ranging from information provision, reflection or active intervention. Ensuring patients’ COVID-19 vaccine acceptance is crucial to help manage the pandemic (Danchin et al. 2020), and GPs see their role as including the provision of reliable information about COVID-19 vaccines and supporting their uptake (Copp et al. 2021). Motivational interviewing may help direct COVID-19 vaccine counselling and subsequent uptake (Breckenridge et al. 2021). Thus, checking and managing a patient’s COVID-19 vaccine acceptance, hesitancy and/or preferencing is another health issue now influencing multiple daily consultations.

In the Royal Australian College of General Practitioners’ (Royal Australian College of General Practitioners (RACGP) 2021a) Health of the Nation report, one-third of respondents indicated they were experiencing financial pressures and difficulty finding a financially viable way to provide COVID-19 vaccinations (Royal Australian College of General Practitioners (RACGP) 2021a). Although the federal government did introduce a Medicare Benefits Scheme item for vaccination counselling on 18 June 2021 (restricted to patients aged over 50 years initially, then available for all from 29 June 2021; Royal Australian College of General Practitioners (RACGP) 2021b), it can only be claimed in conjunction with a Medicare Benefits Scheme vaccination administration item, and thus was largely inaccessible at the times counselling was taking place (Woodley 2021). Our survey demonstrates that vaccine counselling, as it happens in practice, represents a significant increase in the workload of general practice, because GPs often take multiple opportunities to support vaccination and seek to move people towards acceptance of vaccination over time, not just immediately preceding actual vaccination. This work, although crucial for advancing vaccination rates, is potentially unremunerated under current funding arrangements, which may have been developed without sufficient regard to the realities of behaviour change in clinical practice.

GPs in this study reported significant vaccine hesitancy and preferencing amongst patients. GPs were more frequently addressing patient concerns about Vaxzevria, in particular its safety and efficacy, and only infrequently addressing concerns about Comirnaty. Following widespread media coverage of thrombosis with thrombocytopenia syndrome cases, Comirnaty rapidly became the preferred vaccine – both officially for persons under 60 years-of-age by the Australian Technical Advisory Group on Immunisation, and more generally among the population; there was also an overall increase in general hesitancy (Tsirtsakis 2021a). While Australia had low case numbers of COVID-19, it is likely people felt that they could wait to access their preferred vaccine. Following outbreaks of COVID-19 disease in NSW and Victoria, vaccination rates increased – both due to greater vaccine availability and increased demand (Hanrahan and Hayman 2021; Scott and Yang 2021). Vaccine hesitancy declined in Australia from 33% in May to 12% in October (Melbourne Institute 2021); however, there are likely to be subpopulations where hesitancy remains higher. Thus, there is an ongoing role for GPs to support their patients by providing counselling around risks and benefits of COVID-19 vaccination and access to COVID-19 vaccines.

Vaccine counselling has been complicated by poor consultation and communication between governments and general practice. GPs in this study expressed frustration that patients or the media were often aware of changes to the vaccination program before health care providers were officially informed. Changes to vaccine advice were announced at short notice, leaving general practices overwhelmed with patient queries (Tsirtsakis 2021b). An earlier study of Australian GPs also found a need for improved communication and resources from the government (Copp et al. 2021). There were mismatches between federally announced stages of the vaccine rollout, and implementation by state jurisdictions. For example, the vaccination rollout was formally extended to all people aged 16 years and over from 30 August 2021, meaning that they could access Comirnaty from that date (Australian Government Department of Health 2021e). However, individual jurisdictions implemented this at different times: South Australia from 16 August (Government of South Australia Department of Human Services 2021), NSW in local government areas of concern only from 19 August (NSW Government Health 2021) and Victoria from 25 August (Premier of Victoria 2021). This led to reports of people cancelling their Vaxzevria appointments in favour of Comirnaty (Sakkal and Fowler 2021), despite access to the vaccine being unable to match eligibility (Premier of Victoria 2021). Governments have a key role in encouraging uptake of vaccinations. It is important that governments consider the timing of advice, and how that impacts health professionals who are counselling patients and providing vaccinations. Clear communication to general practice prior to public announcements would facilitate providers being informed and proactive in communicating with and providing services to the community (Lim and Nguyen 2021).

The COVID-19 pandemic has led to significant baseline stress on general practice (Royal Australian College of General Practitioners (RACGP) 2021a), not wholly related to local case numbers; a phenomenon also observed by our colleagues in New Zealand, Canada and the USA (Annals of Family Medicine COVID-19 Collection 2021a, 2021b). Stress caused by the pandemic is at least partly due to GPs managing increased workloads since it began (Kippen et al. 2020) and navigating changes to their models of practice (Wright et al. 2020). Stress has also been attributed to the burden of providing COVID-19 vaccinations and counselling (Royal Australian College of General Practitioners (RACGP) 2021a). Although there is sustained baseline stress on general practice, it is unsurprising that it is increased during outbreaks and lockdowns.

At the time of fielding our survey, the Delta variant outbreak in Australia was only affecting NSW (Australian Government Department of Health 2021d). This may account for higher average strain on practice reported in NSW compared with the rest of the country, consistent with trends observed in Victoria during their second wave outbreak in 2020 (Annals of Family Medicine COVID-19 Collection 2021a). Respondents in NSW also reported more time added on to consultations on average compared with their colleagues elsewhere. Patients in NSW were more likely to present with concerns about access to COVID-19 vaccines, which is unsurprising, as increased demand for vaccines was associated with the Delta outbreak (Hanrahan and Hayman 2021; Scott and Yang 2021).

Our study is the first that we are aware of that explores general practice experiences of vaccination counselling and provision in Australia during the COVID-19 pandemic. A key benefit of our survey series is that it is fielded and analysed over a short period of time, leading to timely reports being available to inform policy makers.

Another strength of our study is that is has been run in parallel with our partners in the USA, Canada and New Zealand. Throughout the series, similar themes and levels of stress and strain have been observed despite the, at times, quite divergent pandemic experiences in different countries (Annals of Family Medicine COVID-19 Collection 2021a, 2021b). The USA was the only other team to conduct a survey in July 2021, their 29th. They received 709 responses from clinicians across 49 states/territories, in a range of settings (The Larry A Green Center 2021). Respondents to the USA survey also discussed difficulties in addressing vaccine hesitancy; 53% reported vaccine hesitancy in unvaccinated patients, with one clinician stating ‘I am exhausted from trying to counter the myths about covid and the vaccine’.

Due to the time constraints of fielding surveys focused on current issues, formal pilot testing of questions could not be conducted.

Our study was a cross-sectional survey, and while we can make commentary on events at a point in time, we cannot infer causation. Although our total number of responses was low, representing a small proportion of the eligible cohort, we have integrated qualitative and quantitative responses from all jurisdictions, urban and rural practices, and different practice types. Response rates cannot be calculated, due to the use of convenience sampling and snowball recruitment, and not knowing how many people received the invitation to participate. We can broadly compare characteristics of our respondents with those of the eligible population (Table 1). A higher proportion of respondents in our study were from NSW/ACT compared with the proportion of GPs registered in those states (38% vs 30% for NSW; 10% vs 2% for ACT). Rural representation (29% of respondents) and clinicians from Aboriginal Community Controlled Health Organisations (4%) was broadly similar to national estimates (26% and 2%, respectively). Thus, although our results may not be truly generalisable, they capture in real time the experiences of a suitably illustrative group of primary health care professionals at a critical juncture in our response to the pandemic.

This paper documents the experiences of Australian GPs in providing vaccine counselling during the COVID-19 pandemic, and may help to inform future pandemic preparedness for vaccine preventable diseases. Australian GPs have played a crucial role in combatting vaccine hesitancy and misinformation as COVID-19 vaccines have been progressively rolled out, building on their substantial expertise and track record in offering routine childhood and annual influenza immunisations. However, this has generated a significant additional burden within GP consultations, against a background of sustained stress and strain throughout the COVID-19 pandemic. As key players in the pandemic vaccination program, GPs must be represented in planning and coordination, with improved consultation and communication from policy makers. Clear and consistent communication from federal and state/territory governments to the public will complement GP efforts by improving community confidence in COVID-19 vaccines.

Supplementary material is available online.

Data are available upon reasonable request.

Dr O’Brien has recently joined the editorial team of AJPH as an Associate Editor. The authors declare no other conflicts of interest.

This research did not receive any specific funding.