Strategies intended to address vaccine hesitancy: Review of published reviews

The vaccination rift effect provides evidence that source vaccination status determines the rejection of calls to get vaccinated

COVID vaccination protects individuals and helps end the pandemic, but a sizable minority in Western countries rejects the vaccine. Vaccination status should serve as a group membership, critical communication between groups undermines trust, and we accordingly suggest that calls to get vaccinated by vaccinated sources lead to defensive rejection instead of desired behavior change. We term this the vaccination rift effect. A unique collaboration with national print, online and TV news media yielded a large (N = 1170), age-representative sample of Austrian citizens for our fully randomized experiment. Participants exhibited the vaccination rift: They ascribed less constructive motives, d = 0.28, 95% CI [0.17; 0.40], experienced more threat, d = - 0.30, 95% CI [- 0.42; - 0.19], and ascribed worse personality characteristics to vaccinated (vs. unvaccinated) commenters, d = 0.17, 95% CI [0.06; 0.29]. Constructiveness consistently predicted behavioral measures of counterarguing and vaccination planning (indirect effects B = 0.033, SE = 0.013 and B = - 0.056, SE = 0.014). The vaccination rift was substantially stronger among the critical group of unvaccinated participants, ds = |0.39-0.52|, than among those fully vaccinated, ds = |0.08-0.17|. We discuss how to apply these psychological mechanics of the vaccination rift to public campaigns.

Counselling of non-communicable diseases' patients for COVID-19 vaccine uptake in Jordan: Evaluating the intervention

BACKGROUND

People with noncommunicable diseases (NCDs) are at a significantly higher risk of worst outcomes if infected with COVID-19 and thus amongst the main target population for vaccination. Despite prioritizing them for vaccination, the number of vaccinated patients with comorbidities stalled post vaccine introduction. Despite that the government along with partners ran a national awareness campaign to ramp up vaccination coverage, the coverage remained suboptimal. Thus, a one-to-one health counselling initiative was implemented to explore the acceptance of COVID-19 vaccines by the NCDs patients and address the main issues surrounding vaccine hesitancy. This study evaluates the impact of this intervention by analyzing the change in COVID-19 vaccine acceptance.

METHODS

In this analytical observational study, a random sample of 57,794 people living with NCDs were approached. Out of them, 12,144 received one-to-one counselling by a group of trained health professionals. The counselled group's vaccine acceptance was assessed on a Likert scale from 1 to 5 pre- and post- counselling. Moreover, a random sample was followed up 2 months after initial counselling to measure their vaccine acceptance and update their vaccination status.

RESULTS

44.5% of total respondents were already registered in the vaccination platform. On a scale from 1 to 5, the overall mean confidence significantly increased by 1.63 from 2.48 pre-counselling to 4.11 post-counselling. Two-months post counselling, a random sample was contacted again and had a mean vaccine confidence of 3.71, which is significantly higher than pre-counselling confidence level despite a significant decrease to post-counselling results.

DISCUSSION

Implementing an intervention that targets all key factors impacting health decisions, such as health literacy, risk appraisal and response efficacy, helps reach an adaptive response and increase vaccine confidence. Scholars should be cautious when implementing an intervention since it could lead to maladaptive defensive responses. One-to-one interventions are more effective in population when addressing new interventions and vaccines.

Best shot: A motivational interviewing approach to address vaccine hesitancy in pediatric outpatient settings

BACKGROUND

Vaccine hesitancy in parents and childhood vaccine refusal is increasing. A standard of care to address this problem has not been identified.

PURPOSE

To identify if the use of motivational interviewing by pediatric providers during routine well child visits, when compared to standard of care, would increase vaccine rates in children 0-12 months of age. Factors associated with vaccine hesitancy were also investigated.

METHODS

A quasi-experimental study was completed on a convenience sample of pediatric providers (N = 6) and caregivers of children 0-12 months of age (N = 66). Four providers were trained to use motivational interviewing. During the well child visit the Parent Attitudes About Childhood Vaccines survey was completed, and the motivational interviewing intervention was implemented. Clinic's data were compared with other clinic data of non-trained providers.

FINDINGS

Vaccine refusal/delays rate was 11.4% among caregivers. Vaccine refusal rate decreased after the intervention (9.00% pre-intervention and 6.40% post-intervention). An ordinal regression identified caregivers with higher vaccine hesitancy scores and more children were more likely to delay or refuse vaccines, while caregivers ≥30 years or with high income were less likely to delay/refuse vaccines. A difference in difference analysis identified that an additional 2.6% of children received vaccines when seen by trained providers compared to non-trained (β = -0.330, OR = 0.719, p = 0.470).

DISCUSSION

Findings indicate a condensed motivational interviewing education session may be clinically significant in decreasing vaccine hesitancy among this population.

APPLICATIONS TO PRACTICE

A more robust study to confirm these findings is recommended prior to practice implementation.

Understanding Primary Care Physician Vaccination Behaviour: A Systematic Review

BACKGROUND

Vaccine hesitancy decreases adult vaccination coverage and has been recognized by WHO as a major health threat. Primary care physicians (PCP) play a key role in vaccination by giving vaccine counselling to their patients. The aim of this systematic review is to identify the knowledge, beliefs, attitudes and barriers (KBAB) associated with own vaccination and patient recommendation in primary care physicians.

METHODS

MEDLINE/PubMed, EMBASE and Cochrane Library databases were used to search and identify relevant studies based on their title and abstract. In the next step, the full text of each previously selected article was read for eligibility. Articles were selected by two independent reviewers and data extraction was performed using tables. The following information was extracted: methodological characteristics, demographic factors, professional characteristics, and intrinsic or extrinsic factors influencing vaccination or recommendation.

RESULTS

Our search yielded 41 eligible papers, data-sources, previous practices, belief in the effectiveness or safety of the vaccine, perceived risk, and trust in health authorities were all shown to be related to own vaccination and patient recommendation.

CONCLUSION

Internet is the main source of information for PCP related to vaccine hesitancy. It is therefore essential to increase the presence and access to pro-vaccination content in this area. In addition, involving PCP in the establishment of vaccination recommendations could improve their credibility in the institutions. On the other hand, training in communication skills and establishing reminder systems could reflect higher vaccination coverage among their patients.

Factors Influencing the Choice to Advise for or against COVID-19 Vaccination in the Physicians and Dentists of an Italian Region

Healthcare workers (HCWs), particularly physicians, are a relevant and trusted source of information for patients, especially when health-related choices such as vaccination are concerned. Between July and November 2022, we administered a web-based survey to physicians and dentists living in the Latio region of Italy to explore whether their background might affect their willingness to recommend the COVID-19 vaccination to their patients (RCVtoPat) and their relatives (RCVtoRel). We performed a multivariable logistic regression to study the association between the two outcomes (RCVtoPat and RCVtoRel) and their potential determinants in our sample (n = 1464). We found that being a dentist, an increasing fear of COVID-19, and having been previously vaccinated against flu are positively associated with both RCVtoPat and RCVtoRel, while a better self-rated knowledge of COVID-19 vaccines is associated only with RCVtoRel. No role was found for age, sex, civil status, education level, information sources, previous SARS-CoV-2 infection, and chronic diseases. A sub-group analysis of physicians alone (n = 1305) demonstrated a positive association with RCVtoRel of being specialized in diagnostic/therapeutic services and a negative effect on RCVtoPat of being trained in general practice. We provide useful insights about the factors that should be addressed to ensure HCWs exert a positive influence on their patients and communities.

A multicentre Canadian survey of caregiver perspectives on COVID vaccine-related pain and stress for their family

Background

Caregiver hesitancy for their children to receive the COVID-19 vaccine remains due to concerns regarding safety and efficacy, but also due to fear of vaccine administration-related pain and distress. Study objectives were to determine caregivers' perceptions regarding both their personal and child's COVID-19 vaccine administration-related stress and fear and relate this to their likelihood to allow their child to receive COVID-19 vaccinations.

Methods

This study was a secondary data analysis of a multicentre, cross-sectional survey of caregivers presenting to four Canadian pediatric emergency departments. Caregivers were surveyed between December 2020 and March 2021 and completed a digital survey on their own smartphones.

Results

331 caregivers responded to the survey (mean age 39.9 years [SD 7.71]); 74.2% (245/331) were mothers. Children's mean age was 8.8 years [SD 5.4]; 49.8% (165/331) were female. 64.1% (209/326) of caregivers were willing to vaccinate their child against COVID-19, while 35.9% (117/326) were not. Greater perceived COVID-19 vaccine administration-related pain (0.88 [0.80; 0.95], p = .003) and stress (0.82 [0.76; 0.89], p = <.001) for their child as well as greater perceived personal stress with their own COVID-19 vaccine administration (0.81 [0.75; 0.88], p = <.001) were associated with caregivers being less likely to vaccinate their child.

Conclusions

During the time period between COVID-19 pandemic waves 2 and 3, and after the vaccine had been federally approved for adults, one-third of Canadian caregivers surveyed reported being unwilling to vaccinate their child against COVID-19 in the future. Managing children's and caregivers' vaccine administration-related fear and stress may improve vaccine uptake for children.

What message appeal and messenger are most persuasive for COVID-19 vaccine uptake: Results from a 5-country survey in India, Indonesia, Kenya, Nigeria, and Ukraine

Effective strategies to encourage COVID-19 vaccination should consider how health communication can be tailored to specific contexts. Our study aimed to evaluate the influence of three specific messaging appeals from two kinds of messengers on COVID-19 vaccine acceptance in diverse countries. We surveyed 953 online participants in five countries (India, Indonesia, Kenya, Nigeria, and Ukraine). We assessed participants’ perceptions of three messaging appeals of vaccination—COVID-19 disease health outcomes, social norms related to COVID-19 vaccination, and economic impact of COVID-19—from two messengers, healthcare providers (HCP), and peers. We examined participants’ ad preference and vaccine hesitancy using multivariable multinomial logistic regression. Participants expressed a high level of approval for all the ads. The healthcare outcome–healthcare provider ad was most preferred among participants from India, Indonesia, Nigeria, and Ukraine. Participants in Kenya reported a preference for the health outcome–peer ad. The majority of participants in each country expressed high levels of vaccine hesitancy. However, in a final logistic regression model participant characteristics were not significantly related to vaccine hesitancy. These findings suggest that appeals related to health outcomes, economic benefit, and social norms are all acceptable to diverse general populations, while specific audience segments (i.e., mothers, younger adults, etc.) may have preferences for specific appeals over others. Tailored approaches, or approaches that are developed with the target audience’s concerns and preferences in mind, will be more effective than broad-based or mass appeals.

The impact factors of social media users' forwarding behavior of COVID-19 vaccine topic: Based on empirical analysis of Chinese Weibo users

Introduction

Social media, an essential source of public access to information regarding the COVID-19 vaccines, has a significant effect on the transmission of information regarding the COVID-19 vaccines and helps the public gain correct insights into the effectiveness and safety of the COVID-19 vaccines. The forwarding behavior of social media users on posts concerned with COVID-19 vaccine topics can rapidly disseminate vaccine information in a short period, which has a significant effect on transmission and helps the public access relevant information. However, the factors of social media users' forwarding posts are still uncertain thus far. In this paper, we investigated the factors of the forwarding COVID-19 vaccines Weibo posts on Chinese social media and verified the correlation between social network characteristics, Weibo textual sentiment characteristics, and post forwarding.

Methods

This paper used data mining, machine learning, sentiment analysis, social network analysis, and regression analysis. Using " (COVID-19 vaccine)" as the keyword, we used data mining to crawl 121,834 Weibo posts on Sina Weibo from 1 January 2021 to 31 May 2021. Weibo posts not closely correlated with the topic of the COVID-19 vaccines were filtered out using machine learning. In the end, 3,158 posts were used for data analysis. The proportions of positive sentiment and negative sentiment in the textual of Weibo posts were calculated through sentiment analysis. On that basis, the sentiment characteristics of Weibo posts were determined. The social network characteristics of information transmission on the COVID-19 vaccine topic were determined through social network analysis. The correlation between social network characteristics, sentiment characteristics of the text, and the forwarding volume of posts was verified through regression analysis.

Results

The results suggest that there was a significant positive correlation between the degree of posting users in the social network structure and the amount of forwarding. The relationship between the closeness centrality and the forwarding volume was significantly positive. The betweenness centrality was significantly positively correlated with the forwarding volume. There was no significant relationship between the number of posts containing more positive sentiments and the forwarding volume of posts. There was a significant positive correlation between the number of Weibo posts containing more negative sentiments and the forwarding volume.

Conclusion

According to the characteristics of users, COVID-19 vaccine posts from opinion leaders, "gatekeepers," and users with high-closeness centrality are more likely to be reposted. Users with these characteristics should be valued for their important role in disseminating information about COVID-19 vaccines. In addition, the sentiment contained in the Weibo post is an important factor influencing the public to forward vaccine posts. Special attention should be paid to the negative sentimental tendency contained in this post on Weibo to mitigate the negative impact of the information epidemic and improve the transmission effect of COVID-19 vaccine information.

COVID-19 vaccine acceptance and perceived risk among pregnant and non-pregnant adults in Cameroon, Africa

Background

The public health response to the global COVID-19 pandemic has varied widely by region. In Africa, uptake of effective COVID-19 vaccines has been limited by accessibility and vaccine hesitancy. The aim of this study was to compare perceptions of COVID-19 infection and vaccination between pregnant women and non-pregnant adults in four regions of Cameroon, located in Central Africa.

Methods

A cross-sectional survey study was conducted at urban and suburban hospital facilities in Cameroon. Participants were randomly selected from a convenience sample of adult pregnant and non-pregnant adults in outpatient clinical settings between June 1st and July 14th, 2021. A confidential survey was administered in person by trained research nurses after obtaining written informed consent. Participants were asked about self-reported sociodemographics, medical comorbidities, perceptions of COVID-19 infection, and vaccination. Descriptive statistics were used for survey responses and univariate and multivariable logistic regression models were created to explore factors associated with COVID-19 vaccine acceptability.

Results

Fewer than one-third of participants were interested in receiving the COVID-19 vaccine (31%, 257/835) and rates did not differ by pregnancy status. Overall, 43% of participants doubted vaccine efficacy, and 85% stated that the vaccine available in Africa was less effective than vaccine available in Europe. Factors independently associated with vaccine acceptability included having children (aOR = 1.5; p = 0.04) and higher education (aOR = 1.6 for secondary school vs primary/none; p = 0.03). Perceived risks of vaccination ranged from death (33%) to fetal harm (31%) to genetic changes (1%). Health care professionals were cited as the most trusted source for health information (82%, n = 681).

Conclusion

COVID-19 vaccine hesitancy and misinformation in Cameroon was highly prevalent among pregnant and non-pregnant adults in 2021 while vaccine was available but not recommended for use in pregnancy. Based on study findings, consistent public health messaging from medical professionals about vaccine safety and efficacy and local production of vaccine are likely to improve acceptability.

Understanding the influence of online information, misinformation, disinformation and reinformation on COVID-19 vaccine acceptance: Protocol for a multicomponent study

Background

The COVID-19 pandemic has generated an explosion in the amount of information shared on the internet, including false and misleading information on SARS-CoV-2 and recommended protective behaviors. Prior to the pandemic, web-based misinformation and disinformation were already identified as having an impact on people’s decision to refuse or delay recommended vaccination for themselves or their children.

Objective

The overall aims of our study are to better understand the influence of web-based misinformation and disinformation on COVID-19 vaccine decisions and investigate potential solutions to reduce the impact of web-based misinformation and disinformation about vaccines.

Methods

Based on different research approaches, the study will involve (1) the use of artificial intelligence techniques, (2) a web-based survey, (3) interviews, and (4) a scoping review and an environmental scan of the literature.

Results

As of September 1, 2022, data collection has been completed for all objectives. The analysis is being conducted, and results should be disseminated in the upcoming months.

Conclusions

The findings from this study will help with understanding the underlying determinants of vaccine hesitancy among Canadian individuals and identifying effective, tailored interventions to improve vaccine acceptance among them.

International Registered Report Identifier (IRRID)

DERR1-10.2196/41012

Beyond coverage: Rural-urban disparities in the timeliness of childhood vaccinations in Tanzania

BACKGROUND

Timely vaccination maximizes efficacy for preventing infectious diseases. In the absence of national vaccination registries, representative sample survey data hold vital information on vaccination coverage and timeliness. This study characterizes vaccination coverage and timeliness in Tanzania and provides an analytic template to inform contextually relevant interventions and evaluate immunization programs.

METHODS

Cross-sectional data on 6,092 children under age 3 from the 2015-16 Tanzania Demographic and Health Survey were used to examine coverage and timeliness for 14 vaccine doses recommended in the first year of life. The Kaplan-Meier method was used to model time to vaccination. Cox proportional hazard models were used to examine factors associated with timely vaccination.

RESULTS

Substantial rural-urban disparities in vaccination coverage and timeliness were observed for all vaccines. Across 14 recommended doses, documented coverage ranged from 52 % to 79 %. Median vaccination delays lasted up to 35 days; gaps were larger among rural than urban children and for later doses in vaccine series. Among rural children, median delays exceeded 35 days for the 3rd doses of the polio, pentavalent, and pneumococcal vaccines. Median delays among urban children were < 21 days for all doses. Among rural and urban children, lower maternal education and delivery at home were associated with increased risk of delayed vaccination. In rural settings, less household wealth and greater distance to a health facility were also associated with increased risk of delayed vaccination.

DISCUSSION

This study highlights persistent gaps in uptake and timeliness of childhood vaccinations in Tanzania and substantial rural-urban disparities. While the results provide an informative situation assessment and outline strategies for identifying unvaccinated children, a national electronic registry is critical for comprehensive assessments of the performance of vaccination programs. The timeliness measure employed in this study-the amount of time children are un- or undervaccinated-may serve as a sensitive performance metric for these programs.

Promoting vaccination during rapid HIV testing: Recommendations from men who have sex with men in California

Community-based rapid HIV testing is effective for reaching racial-ethnically diverse men who have sex with men (MSM), offering an opportunity for bundled health promotion interventions. Given MSM experience a heightened prevalence of human papillomavirus (HPV) and meningococcal disease, we examined their preferences for bundling rapid HIV testing with an intervention to promote vaccination against these infections. In 2020, we conducted five virtual focus groups (N = 25 participants) in English and Spanish with MSM in Southern California's Inland Empire. Participants discussed their knowledge about HPV and meningitis vaccination and attitudes toward receiving vaccination information and referrals during rapid HIV tests. We used the rigorous and accelerated data reduction technique to systematically analyse the data. Participants had a mean age of 30, were socioeconomically diverse, and predominantly (68%) Hispanic. 96% had ever been tested for HIV, while only 28% were vaccinated against HPV and/or meningitis. Most participants were unaware of MSM's elevated risk for HPV and meningitis and were eager to receive vaccination information from LGBTQ+-friendly providers. However, many participants emphasised rapid HIV testing was stressful and anticipated feeling overwhelmed if presented with vaccination information in this setting. Preferred formats for vaccine promotion included pamphlets and resources that could be discretely accessed online, supported by broader advertising featuring diverse MSM on social media, dating apps, and posters in the community. Overall, our findings suggest that bundling health promotion messages with rapid HIV testing may be ineffective, as the anxiety associated with taking an HIV test may interfere with such messages and their impact.

Adult vaccination uptake strategies in low- and middle-income countries: A systematic review

BACKGROUND

Evidence-based strategies can maximize vaccination intent and uptake among adults. This systematic review summarizes the existing literature on strategies to improve vaccination intent and uptake among adults in low- and middle-income countries (LMICs) to inform future implementation in various populations and contexts.

METHODS

Eligible studies were identified through a systematic search in Medline, Embase, Cochrane Libraries, as well as grey literature databases published between January 2010 and March 2021. The search was limited to studies in LMICs that evaluated adult vaccination interventions. Data were extracted from the included studies and evaluated against the World Health Organization's Behavioral and Social Drivers of Vaccination Framework. The National Institutes of Health study quality assessment tools were used to evaluate study quality.

RESULTS

The initial literature review identified 2,854 records, 22 of which met the inclusion criteria. The majority (n = 19 or 86%) of studies were from middle-income countries, with the remaining studies (n = 3 or 13%) set in low-income countries. The majority (15/22, 68%) of interventions were multi-component. 82% (18/22) of studies addressed thoughts and feelings, 59% (13/22) addressed social processes, and 73% (16/22) addressed practical issues. Five studies reported primary outcomes of vaccination intent, and the remaining 17 reported vaccine uptake. 36% (8/22) of the studies cited statistically significant positive intervention effects on vaccination intent or uptake. Few of the included studies (6/22, 27%) were RTCs, and most studies (15/22, 68%) were of poor study quality. The studies reporting the highest increase in vaccination intent and uptake were multi-component interventions that addressed all three determinants of vaccination.

DISCUSSION

The results of this review highlight levers that can be used to encourage vaccine intent and uptake in the ongoing rollout of COVID-19 vaccines, as well as the deployment of other vaccines to adult populations in LMICs. Of the included studies, multicomponent interventions were most effective, mainly when targeting multiple determinants of vaccination. However, poor study quality indicates the need for additional research to validate these findings.

Using a cognitive network model of moral and social beliefs to explain belief change

Skepticism toward childhood vaccines and genetically modified food has grown despite scientific evidence of their safety. Beliefs about scientific issues are difficult to change because they are entrenched within many interrelated moral concerns and beliefs about what others think. We propose a cognitive network model that estimates network ties between all interrelated beliefs to calculate the overall dissonance and interdependence. Using a probabilistic nationally representative longitudinal study, we test whether our model can be used to predict belief change and find support for our model's predictions: High network dissonance predicts subsequent belief change, and people are driven toward lower network dissonance. We show the advantages of measuring dissonance using the belief network structure compared to traditional measures. This study is the first to combine a unifying predictive model with an experimental intervention and to shed light on the dynamics of dissonance reduction leading to belief change.

A workshop to co-design messages that may increase uptake of vaccines: A case study

The present case study describes a co-produced and theoretically informed workshop wherein messages were co-designed to increase the uptake of future COVID-19 vaccines in the United Kingdom. Co-design can enhance the legitimacy and effectiveness of public interventions, but many researchers, service providers, and policymakers may be uncertain where to start. This demonstrative example applies behavioural science and design thinking theory, illustrating how others can integrate theoretically informed co-design into similar and more complex projects efficiently. The workshop brought together members of the public, immunisers, and public health specialists. A narrative analysis was conducted to identify themes related to vaccine hesitancy. The workshop's supporting materials are made available as supplemental materials, which can be modified for future workshops. The discussion encourages additional workshops to be conducted, including diverse members of the public, to co-design novel solutions to improve public health more generally.

Design and implementation of tailored intervention to increase vaccine acceptance in a Somali community in Stockholm, Sweden - based on the Tailoring Immunization Programmes approach

Objectives

Sweden has had a high and stable vaccination coverage for measles-mumps-rubella (MMR) vaccine (>96%) through the national immunization program (NIP), but coverage rates highlight local pockets of lower vaccination coverage. This project addressed low MMR vaccine acceptance among parents in a Somali community, in Stockholm. The objective of the intervention was to increase vaccine confidence and MMR-vaccine uptake and also to inform practices addressing vaccine acceptance.

Study design

This paper describes the design and implementation of a multi-component intervention based on the Tailoring Immunization Programmes (TIP) approach, developed by the WHO European Regional Office.

Methods

The theoretical underpinning of TIP is the Capability, Opportunity, and Motivation Model (COM-B model) and Behaviour Change Wheel framework (BCW), adapted for vaccination. The COM-model was used to identify barriers and drivers to vaccination and intervention types. The TIP-phases described in this paper are: pre-TIP (planning), three succeeding TIP phases (situational analysis, formative research, intervention design) and the post-TIP phase (implementation).

Results

The situation analysis and formative research revealed that parents feared the MMR vaccine due to autism or that their child would stop talking following vaccination, despite lack of scientific evidence for an association between autism and MMR vaccines. Barriers were linked to their associated COM-B factors and mapped to appropriate intervention types for two target groups: Somali parents and nurses at the Child Health Centres (CHC). Selected intervention types targeting parents were education, persuasion and modelling whereas education and training were selected for CHC nurses. The intervention activities included community engagement for parents, while the activities for nurses focused on improving encounters and dialogue with parents having low vaccine acceptance. Following the intervention design the activities were developed, pilot tested and implemented.

Conclusion

This study confirm that the TIP approach is valuable for guiding a stepwise working process for a thorough understanding of barriers and drivers for MMR vaccination among parents in this Somali community. It facilitated the design of a theory and evidence-informed intervention targeting parents and nurses.

Communicating about COVID-19 vaccine development and safety

PURPOSE

Beliefs that the risks from a COVID-19 vaccine outweigh the risks from getting COVID-19 and concerns that the vaccine development process was rushed and lacking rigor have been identified as important drivers of hesitancy and refusal to get a COVID-19 vaccine. We tested whether messages designed to address these beliefs and concerns might promote intentions to get a COVID-19 vaccine.

METHOD

We conducted an online survey fielded between March 8-23, 2021 with US Veteran (n = 688) and non-Veteran (n = 387) respondents. In a between-subjects experiment, respondents were randomly assigned to a control group (with no message) or to read one of two intervention messages: 1. a fact-box styled message comparing the risks of getting COVID-19 compared to the vaccine, and 2. a timeline styled message describing the development process of the COVID-19 mRNA vaccines.

RESULTS

Most respondents (60%) wanted a COVID-19 vaccine. However, 17% expressed hesitancy and 23% did not want to get a COVID-19 vaccine. The fact-box styled message and the timeline message did not significantly improve vaccination intentions, F(2,358) = 0.86, p = .425, [Formula: see text] = .005, or reduce the time respondents wanted to wait before getting vaccinated, F(2,306) = 0.79, p = .453, [Formula: see text] = .005, compared to no messages.

DISCUSSION

In this experimental study, we did not find that providing messages about vaccine risks and the development process had an impact on respondents' vaccine intentions. Further research is needed to identify how to effectively address concerns about the risks associated with COVID-19 vaccines and the development process and to understand additional factors that influence vaccine intentions.

Interventions to increase COVID-19 vaccine uptake: a scoping review

BACKGROUND

Vaccines are effective in preventing severe COVID-19, a disease for which few treatments are available and which can lead to disability or death. Widespread vaccination against COVID-19 may help protect those not yet able to get vaccinated. In addition, new and vaccine-resistant mutations of SARS-CoV-2 may be less likely to develop if the spread of COVID-19 is limited. Different vaccines are now widely available in many settings. However, vaccine hesitancy is a serious threat to the goal of nationwide vaccination in many countries and poses a substantial threat to population health. This scoping review maps interventions aimed at increasing COVID-19 vaccine uptake and decreasing COVID-19 vaccine hesitancy.

OBJECTIVES

To scope the existing research landscape on interventions to enhance the willingness of different populations to be vaccinated against COVID-19, increase COVID-19 vaccine uptake, or decrease COVID-19 vaccine hesitancy, and to map the evidence according to addressed populations and intervention categories.

SEARCH METHODS

We searched Cochrane COVID-19 Study Register, Web of Science (Science Citation Index Expanded and Emerging Sources Citation Index), WHO COVID-19 Global literature on coronavirus disease, PsycINFO, and CINAHL to 11 October 2021.

SELECTION CRITERIA

We included studies that assess the impact of interventions implemented to enhance the willingness of different populations to be vaccinated against COVID-19, increase vaccine uptake, or decrease COVID-19 vaccine hesitancy. We included randomised controlled trials (RCTs), non-randomised studies of intervention (NRSIs), observational studies and case studies with more than 100 participants. Furthermore, we included systematic reviews and meta-analyses. We did not limit the scope of the review to a specific population or to specific outcomes assessed. We excluded interventions addressing hesitancy towards vaccines for diseases other than COVID-19.

DATA COLLECTION AND ANALYSIS

Data were analysed according to a protocol uploaded to the Open Science Framework. We used an interactive scoping map to visualise the results of our scoping review. We mapped the identified interventions according to pre-specified intervention categories, that were adapted to better fit the evidence. The intervention categories were: communication interventions, policy interventions, educational interventions, incentives (both financial and non-financial), interventions to improve access, and multidimensional interventions. The study outcomes were also included in the mapping. Furthermore, we mapped the country in which the study was conducted, the addressed population, and whether the design was randomised-controlled or not.

MAIN RESULTS

We included 96 studies in the scoping review, 35 of which are ongoing and 61 studies with published results. We did not identify any relevant systematic reviews. For an overview, please see the interactive scoping map (https://tinyurl.com/2p9jmx24) STUDIES WITH PUBLISHED RESULTS Of the 61 studies with published results, 46 studies were RCTs and 15 NRSIs. The interventions investigated in the studies were heterogeneous with most studies testing communication strategies to enhance COVID-19 vaccine uptake. Most studies assessed the willingness to get vaccinated as an outcome. The majority of studies were conducted in English-speaking high-income countries. Moreover, most studies investigated digital interventions in an online setting. Populations that were addressed were diverse. For example, studies targeted healthcare workers, ethnic minorities in the USA, students, soldiers, at-risk patients, or the general population.  ONGOING STUDIES Of the 35 ongoing studies, 29 studies are RCTs and six NRSIs. Educational and communication interventions were the most used types of interventions. The majority of ongoing studies plan to assess vaccine uptake as an outcome. Again, the majority of studies are being conducted in English-speaking high-income countries. In contrast to the studies with published results, most ongoing studies will not be conducted online. Addressed populations range from minority populations in the USA to healthcare workers or students. Eleven ongoing studies have estimated completion dates in 2022.   AUTHORS' CONCLUSIONS: We were able to identify and map a variety of heterogeneous interventions for increasing COVID-19 vaccine uptake or decreasing vaccine hesitancy. Our results demonstrate that this is an active field of research with 61 published studies and 35 studies still ongoing. This review gives a comprehensive overview of interventions to increase COVID-19 vaccine uptake and can be the foundation for subsequent systematic reviews on the effectiveness of interventions to increase COVID-19 vaccine uptake.  A research gap was shown for studies conducted in low and middle-income countries and studies investigating policy interventions and improved access, as well as for interventions addressing children and adolescents. As COVID-19 vaccines become more widely available, these populations and interventions should not be neglected in research.

AUTHORS CONCLUSIONS

We were able to identify and map a variety of heterogeneous interventions for increasing COVID-19 vaccine uptake or decreasing vaccine hesitancy. Our results demonstrate that this is an active field of research with 61 published studies and 35 studies still ongoing. This review gives a comprehensive overview of interventions to increase COVID-19 vaccine uptake and can be the foundation for subsequent systematic reviews on the effectiveness of interventions to increase COVID-19 vaccine uptake.  A research gap was shown for studies conducted in low and middle-income countries and studies investigating policy interventions and improved access, as well as for interventions addressing children and adolescents. As COVID-19 vaccines become more widely available, these populations and interventions should not be neglected in research.

Characteristics associated with COVID-19 vaccine hesitancy

Understanding what lies behind actual COVID-19 vaccine hesitancy is fundamental to help policy makers increase vaccination rates and reach herd immunity. We use June 2021 data from the COME-HERE survey to explore the predictors of actual vaccine hesitancy in France, Germany, Italy, Luxembourg, Spain and Sweden. We estimate a linear-probability model with a rich set of covariates and address issues of common-method variance. 13% of our sample say they do not plan to be vaccinated. Post-Secondary education, home-ownership, having an underlying health condition, and one standard-deviation higher age or income are all associated with lower vaccine hesitancy of 2-4.5% points. Conservative-leaning political attitudes and a one standard-deviation lower degree of confidence in the government increase this probability by 3 and 6% points respectively. Vaccine hesitancy in Spain and Sweden is significantly lower than in the other countries.

Evaluating the relationship between moral values and vaccine hesitancy in Great Britain during the COVID-19 pandemic: A cross-sectional survey

RATIONAL/OBJECTIVE

Mandating vaccinations can harm public trust, and informational interventions can backfire. An alternative approach could align pro-vaccination messages with the automatic moral values and intuitions that vaccine-hesitant people endorse. The current study evaluates the relationships between six automatic moral intuitions and vaccine hesitancy.

METHODS

A cross-sectional survey was designed using Qualtrics (2020) software and conducted online from April 6th to April 13, 2021. A representative sample of 1201 people living in Great Britain took part, of which 954 (514 female) passed the attention check items. Participants responded to items about their automatic moral intuitions, vaccination behaviours or intentions related to COVID-19 vaccines, and general vaccine hesitancy. Regressions (with and without adjustments for age, gender, and ethnicity) were performed assessing the association between endorsement of each automatic intuition and self-reported uptake of COVID-19 vaccines, and between each automatic intuition and general vaccine hesitancy.

RESULTS

People who endorsed the authority foundation and those who more strongly endorsed the liberty foundation tended to be more vaccine hesitant. This pattern generalises across people's self-reported uptake of COVID-19 vaccines and people's hesitancy towards vaccines in general. To a lesser extent people who expressed less need for care and a greater need for sanctity also displayed greater hesitancy towards vaccines in general. The results were consistent across the adjusted and non-adjusted analyses. Age and ethnicity significantly contributed to some models but gender did not.

CONCLUSION

Four automatic moral intuitions (authority, liberty, care, and sanctity) were significantly associated with vaccine hesitancy. Foundation-aligned messages could be developed to motivate those people who may otherwise refuse vaccines, e.g., messages that strongly promote liberty or that de-emphasize authority voices. This suggestion moves away from mandates and promotes the inclusion of a more diverse range of voices in pro-vaccination campaigns.

Can targeted messages reduce COVID-19 vaccination hesitancy? A randomized trial

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We find no evidence that tailoring public health communication regarding COVID-19 vaccination for broad demographic groups would increase its effectiveness.

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A post hoc analysis finds that a vaccine endorsement from Dr. Fauci reduces stated intent to vaccinate among conservatives.

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We recommend further research on communicators and endorsers, as well as incentives.

Background

Widespread vaccination is certainly a critical element in successfully fighting the COVID-19 pandemic. We apply theories of social identity to design targeted messaging to reduce vaccine hesitancy among groups with low vaccine uptake, such as African Americans and political conservatives.

Methods

Participants. We conducted an online experiment from April 7 to 27, 2021, that oversampled Black, Latinx, conservative, and religious U.S. residents. We first solicited the vaccination status of over 10,000 individuals. Of the 4,609 individuals who reported being unvaccinated, 4,190 enrolled in our covariate-adaptive randomized trial.

Interventions. We provided participants messages that presented the health risks of COVID-19 to oneself and others; they also received messages about the benefits of a COVID-19 vaccine and an endorsement by a celebrity. Messages were randomly tailored to each participant’s identities—Black, Latinx, conservative, religious, or being a parent.

Outcomes. Respondents reported their intent to obtain the vaccine for oneself and, if a parent, for one’s child.

Results

We report results for the 2,621 unvaccinated respondents who passed an incentivized manipulation check. We find no support for the hypothesis that customized messages or endorsers reduce vaccine hesitancy among our segments. A post hoc analysis finds evidence that a vaccine endorsement from Dr. Fauci reduces stated intent to vaccinate among conservatives.

Conclusions

We find no evidence that tailoring public-health communication regarding COVID-19 vaccination for broad demographic groups would increase its effectiveness. We recommend further research on communicators and endorsers, as well as incentives.

Public Vaccination Reluctance: What Makes Us Change Our Minds? Results of A Longitudinal Cohort Survey

The paper presents a longitudinal cohort survey on the public acceptability of COVID-19 vaccination and real vaccination levels. A survey on a representative sample of adult Polish citizens (n = 1066) was conducted in June 2020 and, one year later, the same group was approached to compare the hypothetical declarations with the real vaccination decisions (n = 438). A significant part of the group that declared reluctance and hesitation toward COVID-19 vaccination before that vaccination was available actually got vaccinated or plans to get vaccinated. Those respondents were asked about the reasons for changing their attitudes. Among the previously vaccine-reluctant individuals, the main reasons included concern about their health and safety (50%) and their desire to travel (26.6%). Vaccine-hesitant individuals also indicated health and safety as their primary concern (69%), as well as the pursuit of herd immunity and a notion of common social safety (12.6%). The main factors helping to increase vaccination acceptance are based on a self-centered pursuit of safety and freedom from restrictions. The survey results may help to prepare a more effective vaccination campaign.

Repeated information of benefits reduces COVID-19 vaccination hesitancy: Experimental evidence from Germany

Background

Many countries, such as Germany, struggle to vaccinate enough people against COVID-19 despite the availability of safe and efficient vaccines. With new variants emerging and the need for booster vaccinations, overcoming vaccination hesitancy gains importance. The research to date has revealed some promising, albeit contentious, interventions to increase vaccination intention. However, these have yet to be tested for their effectiveness in increasing vaccination rates.

Methods & results

We conducted a preregistered survey experiment with N = 1,324 participants in Germany in May/June 2021. This was followed by a series of emails reminding participants to get vaccinated in August and concluded with a follow-up survey in September. We experimentally assess whether debunking vaccination myths, highlighting the benefits of being vaccinated, or sending vaccination reminders decreases hesitancy. In the survey experiment, we find no increase in the intention to vaccinate regardless of the information provided. However, communicating vaccination benefits over several weeks reduced the likelihood of not being vaccinated by 9 percentage points, which translates into a 27% reduction compared to the control group. Debunking vaccination myths and reminders alone also decreased the likelihood, yet not significantly.

Discussion

Our findings suggest that if soft governmental interventions such as information campaigns are employed, highlighting benefits should be given preference over debunking vaccination myths. Furthermore, it seems that repeated messages affect vaccination action while one-time messages might be insufficient, even for increasing vaccination intentions. Our study highlights the importance of testing interventions outside of survey experiments that are limited to measuring vaccination intentions—not actions—and immediate changes in attitudes and intentions—not long-term changes.

Addressing vaccine hesitancy and resistance for COVID-19 vaccines

The COVID-19 vaccine rollout has had various degrees of success in different countries. Achieving high levels of vaccine coverage is key to responding to and mitigating the impact of the pandemic on health and aged care systems and the community. In many countries, vaccine hesitancy, resistance, and refusal are emerging as significant barriers to immunisation uptake and the relaxation of policies that limit everyday life. Vaccine hesitancy/ resistance/ refusal is complex and multi-faceted. Individuals and groups have diverse and often multiple reasons for delaying or refusing vaccination. These reasons include: social determinants of health, convenience, ease of availability and access, health literacy understandability and clarity of information, judgements around risk versus benefit, notions of collective versus individual responsibility, trust or mistrust of authority or healthcare, and personal or group beliefs, customs, or ideologies. Published evidence suggests that targeting and adapting interventions to particular population groups, contexts, and specific reasons for vaccine hesitancy/ resistance may enhance the effectiveness of interventions. While evidence regarding the effectiveness of interventions to address vaccine hesitancy and improve uptake is limited and generally unable to underpin any specific strategy, multi-pronged interventions are promising. In many settings, mandating vaccination, particularly for those working in health or high risk/ transmission industries, has been implemented or debated by Governments, decision-makers, and health authorities. While mandatory vaccination is effective for seasonal influenza uptake amongst healthcare workers, this evidence may not be appropriately transferred to the context of COVID-19. Financial or other incentives for addressing vaccine hesitancy may have limited effectiveness with much evidence for benefit appearing to have been translated across from other public/preventive health issues such as smoking cessation. Multicomponent, dialogue-based (i.e., communication) interventions are effective in addressing vaccine hesitancy/resistance. Multicomponent interventions that encompasses the following might be effective: (i) targeting specific groups such as unvaccinated/under-vaccinated groups or healthcare workers, (ii) increasing vaccine knowledge and awareness, (iii) enhanced access and convenience of vaccination, (iv) mandating vaccination or implementing sanctions against non-vaccination, (v) engaging religious and community leaders, (vi) embedding new vaccine knowledge and evidence in routine health practices and procedures, and (vii) addressing mistrust and improving trust in healthcare providers and institutions via genuine engagement and dialogue. It is universally important that healthcare professionals and representative groups, as often highly trusted sources of health guidance, should be closely involved in policymaker and health authority decisions regarding the establishment and implementation of vaccine recommendations and interventions to address vaccine hesitancy.

Nurses’ Influenza Vaccination and Hesitancy: A Systematic Review of Qualitative Literature

Vaccine hesitancy (VH) is defined as “delaying or refusing a secure vaccine despite its availability”. This hesitancy affects caregivers and more specifically nurses. The purpose of this study is to assess determinants of influenza VH in the nurse’s community. We conducted a systematic review of qualitative literature according to criteria of Preferred Reporting Items for Systematic Review and Meta-Analysis and Enhancing Transparency in Reporting the synthesis of Qualitative Research from 2009 until October 2020. Eleven qualitative studies analysed (ten thematic content analyses and one grounded theory method) found three main factors in VH. The first determinant was the benefit–risk equation considered as unfavourable due to an ineffective vaccine and fears about adverse effects as the pain of the injection. Wrong immunological beliefs brought into hesitancy. Disease barriers (hand washing and masks) and personal immunity were regarded as more effective than the vaccine. Lastly, dehumanised vaccination and the difficulties of access to healthcare were institutional determinants. Nurses ask for a vaccine promotion by hierarchy and doctors with transparent information and respect for autonomy. The availability of vaccines and methods of pain control seem to be some tracks to reduce nurses’ VH.

Countering vaccine hesitancy through medical expert endorsement

Scientists and medical experts are among the professionals trusted the most. Are they also the most suitable figures to convince the general public to get vaccinated? In a pre-registered experiment, we tested whether expert endorsement increases the effectiveness of debunking messages about COVID-19 vaccines. We monitored a sample of 2,277 people in Italy through a longitudinal study along the salient phases of the vaccination campaign. Participants received a series of messages endorsed by either medical researchers (experimental group) or by generic others (control). In order to minimise demand effects, we collected participants’ responses always at ten days from the last debunking message. Whereas we did not find an increase in vaccination behaviour, we found that participants in the experimental group displayed higher intention to vaccinate, as well as more positive beliefs about the protectiveness of vaccines. The more debunking messages the participants received, the greater the increase in vaccination intention in the experimental group compared to control. This suggests that multiple exposure is critical for the effectiveness of expert-endorsed debunking messages. In addition, these effects are significant regardless of participants’ trust toward science. Our results suggest that scientist and medical experts are not simply a generally trustworthy category but also a well suited messenger in contrasting disinformation during vaccination campaigns.

Barriers to adult vaccination in Canada: A qualitative systematic review

Background:

In recent years, Canadian health care professionals have observed an increase in vaccine refusal. The objective of this study is to review published literature and identify the main themes related to vaccine hesitancy and barriers to vaccination in Canadian adults and recent immigrants.

Methods:

A qualitative systematic review was performed. A comprehensive search of MEDLINE (1946 to January 2021) and EMBASE (1974 to January 2021) was conducted to identify existing literature that addressed the primary research question. Studies were eligible for inclusion if the study population involved 1) the general population, 2) Indigenous populations, 3) recent immigrants to Canada or 4) Canadian health care professionals.

Results:

Thirty-four studies were included with a focus on the general population (n = 22), health care professionals (n = 10) and recent immigrant populations (n = 2). The most frequently reported barriers were lack of vaccine information (41%), lack of access to vaccination (38%), fear of adverse reactions (38%), financial reasons (29%), lack of awareness of vaccine existence (29%), antivaccine sentiments (24%), notion that older adults do not need vaccination (18%), misconceptions on vaccine effectiveness (12%), potential sexual health promotion stigma (6%) and fear of needles (3%).

Interpretation:

Barriers to vaccination among Canadians and recent immigrants continue to be a challenge in the health care system.

Conclusions:

The greatest yield in improving vaccination rates is likely to come from supporting vaccine-hesitant individuals in shifting their thinking to greater vaccine acceptance. Pharmacists are well positioned to address vaccine hesitancy and involvement through education, facilitation and administration of vaccines. Can Pharm J (Ott) 2022;155:xx-xx.

A randomized controlled trial of a video intervention shows evidence of increasing COVID-19 vaccination intention

Increasing acceptance of COVID-19 vaccines is imperative for public health. Previous research on educational interventions to overcome vaccine hesitancy have shown mixed effects in increasing vaccination intention, although much of this work has focused on parental attitudes toward childhood vaccination. In this study, we conducted a randomized controlled trial to investigate whether vaccination intention changes after viewing an animated YouTube video explaining how COVID-19 mRNA vaccines work. We exposed participants to one of four interventions–watching the video with a male narrator, watching the same video with a female narrator, reading the text of the transcript of the video, or receiving no information (control group). We found that participants who watched the version of the video with a male narrator expressed statistically significant increased vaccination intention compared to the control group. The video with a female narrator had more variation in results. As a whole, there was a non-significant increased vaccination intention when analyzing all participants who saw the video with a female narrator; however, for politically conservative participants there was decreased vaccination intention for this intervention compared to the control group at a threshold between being currently undecided and expressing probable interest. These results are encouraging for the ability of interventions as simple as YouTube videos to increase vaccination propensity, although the inconsistent response to the video with a female narrator demonstrates the potential for bias to affect how certain groups respond to different messengers.

COVID-19 Vaccination Hesitancy: A Review of the Literature and Recommendations

Vaccines are important to improve immunity against pathogens and diseases. The current COVID-19 disease is rapidly evolving and spreading among people; therefore, it is important to utilize a proper vaccination strategy against it. Currently, many approved vaccines are available and accessible; however, there is a reported hesitancy against taking them among the public and even the health care workers. Mainly, this is attributed to the fear of the possible side effects and complications. Moreover, inaccurate knowledge disseminated through the media/social media especially by those who lack proper expertise adds confusion and more fear that affects the vaccination decision. For such reasons, it is essential to find strategies to increase the acceptability of vaccines and to enhance confidence in the vaccination process. This should be accompanied by sufficient efforts and proper clinical studies to confirm the value and the safety of the vaccines. Those strategies are important to avoid the further spread of the COVID-19 disease and to abort the pandemic worldwide, especially when considering the likely approach towards a COVID-19 booster vaccination program, in which booster vaccines are re-taken along intervals to adequately contain the rapidly evolving nature of the virus. This review article highlights the factors influencing the acceptability of the COVID-19 vaccination and enrollment in clinical trials among the public and some specific populations. Furthermore, it summarizes the suggested strategies and recommendations that can improve the attitudes towards COVID-19 vaccination programs.

COVID-19 Vaccine Hesitancy Among Older Adolescents and Young Adults: A National Cross-Sectional Study in China

Background

With promotion of COVID-19 vaccinations, there has been a corresponding vaccine hesitancy, of which older adolescents and young adults represent groups of particular concern. In this report, we investigated the prevalence and reasons for vaccine hesitancy, as well as potential risk factors, within older adolescents and young adults in China.

Methods

To assess these issues, an online survey was administered over the period from March 14 to April 15, 2021. Older adolescents (16–17 years old) and young adults (18–21 years old) were recruited nationwide from Wechat groups and results from a total of 2,414 respondents were analyzed. Socio-demographic variables, vaccine hesitancy, psychological distress, abnormal illness behavior, global well-being and social support were analyzed in this report.

Results

Compared to young adults (n = 1,405), older adolescents (n = 1,009) showed higher prevalence rates of COVID-19 vaccine hesitancy (16.5 vs. 7.9%, p < 0.001). History of physical diseases (p = 0.007) and abnormal illness behavior (p = 0.001) were risk factors for vaccine hesitancy among older adolescents, while only a good self-reported health status (p = 0.048) was a risk factor for young adults. Concerns over COVID-19 vaccine side effects (67.1%) and beliefs of invulnerability regarding infection risk (41.9%) were the most prevalent reasons for vaccine hesitancy. Providing evidence on the vaccine reduction of COVID-19 infection risk (67.5%), ensuring vaccine safety (56.7%) and the low risk of side effects (52.7%) were the most effective persuasions for promoting vaccinations.

Conclusion

In China, older adolescents showed a higher prevalence for vaccine hesitancy than that of young adults. Abnormal illness behavior and history of physical diseases were risk factors for vaccine hesitancy among these older adolescents, while social support represents an important factor which could help to alleviate this hesitancy.

Minimal effects from injunctive norm and contentiousness treatments on COVID-19 vaccine intentions: evidence from 3 countries

Does information about how other people feel about COVID-19 vaccination affect immunization intentions? We conducted preregistered survey experiments in Great Britain (5,456 respondents across 3 survey waves from September 2020 to February 2021), Canada (1,315 respondents in February 2021), and the state of New Hampshire in the United States (1,315 respondents in January 2021). The experiments examine the effects of providing accurate public opinion information to people about either public support for COVID-19 vaccination (an injunctive norm) or public beliefs that the issue is contentious. Across all 3 countries, exposure to this information had minimal effects on vaccination intentions even among people who previously held inaccurate beliefs about support for COVID-19 vaccination or its perceived contentiousness. These results suggest that providing information on public opinion about COVID vaccination has limited additional effect on people's behavioral intentions when public discussion of vaccine uptake and intentions is highly salient.

Public Attitude Towards COVID-19 Vaccination: Validation of COVID-Vaccination Attitude Scale (C-VAS)

Introduction

The fear of emergence of newer strains of SARS-CoV-2 as well as concerns of waning of protection after doses of COVID-19 vaccine has created a degree of global uncertainty surrounding the pandemic. Some of the emerging strains of SARS-CoV-2 have shown potential for causing serious disease and death, a threat that has been ameliorated by ensuring the vaccine coverage in populations. Still, the vaccine coverage remains unsatisfactory in certain populations. Hence, understanding and working on the factors which affect acceptance of the vaccine amongst the public can be considered a priority for public health as much as ensuring availability of the vaccines.

Objective

This research work aims to build and validate a scale to assess the public attitude towards COVID vaccination. The proposed scale has been named as COVID Vaccination Attitude Scale (C-VAS).

Materials and Methods

A three-stage process was used to develop the C-VAS which includes (1) item generation (deductive and inductive approach); (2) item-refinement (pre-testing and pilot testing, exploratory factor analysis (EFA); and (3) scale validation (confirmatory factor analysis, CFA). The sample size used for this research was 840. In order to overcome the issue of common method bias, the data was collected in two phases. The sample n1 (411) was used for EFA and the sample n2 (429) was employed for undertaking CFA. Common method bias was assessed to check if variations in responses are caused by the instrument instead of the actual dispositions of the respondents. Items of the scale were taken by reviewing the extant literature about vaccination, from the relevant established theories such as health belief model and by interviewing with domain experts. The content validity of the scale was determined.

Results

EFA extracted five factors, labelled as "Perceived Benefits", "Perceived Barriers", "Perceived Severity", "Health Motivation" and "Perceived Risk". To further validate the factor-item structure CFA was performed.

Conclusion

The measurement model was assessed by applying CFA to examine the reliability, accuracy and validity of the scale. Development of this scale can help in understanding factors that affect vaccine acceptability behavior. This can be used in promoting COVID vaccine coverage in countries and societies which still have low vaccination rates especially due to lack of acceptance of the vaccine. This scale also has the potential to understand public behavior in relation to similar future outbreaks and the acceptance of the mitigatory vaccines.

COVID-19 Vaccine Hesitancy Among Healthcare Providers

OBJECTIVE

Vaccine hesitancy among healthcare providers can compromise public confidence in vaccination during the ongoing COVID-19 global epidemic and increase susceptibility to life-threatening disease. We sought to investigate predictors of openness to vaccination among healthcare workers who choose not to be vaccinated against COVID-19 in order to explore potential solutions.

METHODS

Physicians, physician assistants, and nurses who chose not to be vaccinated were surveyed to decipher reasons for vaccine refusal and personal loss due to the virus along with demographic variables. Multivariate logistic regression analysis evaluated whether provider role, parenthood, and death of family or friends were associated with strong versus relative vaccine refusal.

RESULTS

The predominant reasons for vaccine hesitancy in this cohort of health care workers who had access to, but chose not to be vaccinated (n=500) were a concern for vaccine side effects (69.6%) and the belief that the vaccines are inadequately studied (61.6%). Being a physician, a parent, and having no experience of death in the family or friends had 2.64 times (95% CI: 1.65-4.23, p < 0.001), 1.72 times (95% CI: 1.05-2.81, p = 0.032), and 1.70 times (95% CI: 1.06-2.72, p = 0.028) the odds of strong vaccine refusal, respectively. Older age (35 and up) respondents were 1.83 times (95% CI: 1.24-2.68, p = 0.002) more likely to be open to vaccination.

Understanding the societal factors of vaccine acceptance and hesitancy: evidence from Hong Kong

OBJECTIVES

Vaccination is considered to be an important public health strategy for controlling the COVID-19 pandemic. Besides subjective evaluations of the vaccine and the health threat, societal factors have been seen as crucial to vaccination decisions. Based on a socioecological perspective, this study examines the role of societal factors in COVID-19 vaccine hesitancy in Hong Kong.

STUDY DESIGN AND METHOD

An online survey was fielded between 25 and 28 June 2021, collecting 2753 complete responses. Multinomial logistic regression was conducted to examine how subjective evaluations of the vaccine (summarised by the 5C model - Confidence, Collective responsibility, Constraints, Complacency and Calculation), threat perception, interpersonal influences and institutional trust contribute to explaining three types of decision - acceptant (vaccinated, scheduled or indicated 'Yes'), hesitant (unvaccinated and indicated 'Maybe' on intention) and resistant (unvaccinated and indicated 'No').

RESULTS

A total of 43.2%, 21.7% and 35.1% of respondents were acceptant, hesitant and resistant. Although the 5C model remained useful in explaining vaccination decisions, respondents were heavily influenced by the decisions of their family, although they were less influenced by friends. Second, respondents tended to accept the vaccine when they had a weaker perception that the act is supportive of the government and were less resistant if they had stronger institutional trust.

CONCLUSION

Under the low-incidence and low-trust environment such as Hong Kong, vaccination decisions are heavily influenced by family's decision and the perception of vaccination as socially and politically desirable. Our findings highlight the importance of a nuanced conception of interpersonal and political influence towards vaccine acceptance/hesitancy.

Safety of an Inactivated SARS-CoV-2 Vaccine Among Healthcare Workers in Turkey: An Online Survey

Background:

As vaccination against coronavirus disase-19 (COVID-19) evolves, hesitancy has become a problematic issue that has gradually spread worldwide. The main reason for vaccine hesitancy is uncertainties about vaccine side effects.

Aims:

To evaluate the safety of an inactivated COVID-19 vaccine, CoronaVac, and determine the risk factors of emergence of side effects.

Study Design:

Cross-sectional study.

Methods:

An online questionnaire was administered via the internet to healthcare workers who received one or two doses of CoronaVac. The online survey consisted of three sections detailing sociodemographic data, COVID-19 history, and post-vaccine side effects. Side effects that occurred in the period starting from immediately after the first vaccination to the end of the 14th day after the second vaccination were recorded.

Results:

A total of 1628 healthcare workers responded to the online survey. Of these, 24.3% had a side effect either after the first or second dose of CoronaVac. Redness and/or pain at the inoculation site, headache, muscle and joint pains, palpitations, and dizziness were the most common side effects. Female sex, age <50 years, and thyroid disorder in the pre-vaccine period were found to be risk factors for the emergence of side effects. Blood pressure control could not be achieved in 2.2% of participants despite medication use, and permanent medication was needed in 2.5% of participants for blood pressure control.

Conclusion:

Almost a quarter of healthcare workers have at least one side effect after the first or second dose of CoronaVac. Female gender, age <50 years, and thyroid disorder appear to be risk factors for the occurrence of side effects.

Lau K, Miraldo M, Hauck K. Bandwagoning, free-riding and heterogeneity in influenza vaccine decisions: An online experiment

'Nudge'-based social norms messages conveying high population influenza vaccination coverage levels can encourage vaccination due to bandwagoning effects but also discourage vaccination due to free-riding effects on low risk of infection, making their impact on vaccination uptake ambiguous. We develop a theoretical framework to capture heterogeneity around vaccination behaviors, and empirically measure the causal effects of different messages about vaccination coverage rates on four self-reported and behavioral vaccination intention measures. In an online experiment, N = 1365 UK adults are randomly assigned to one of seven treatment groups with different messages about their social environment's coverage rate (varied between 10% and 95%), or a control group with no message. We find that treated groups have significantly greater vaccination intention than the control. Treatment effects increase with the coverage rate up to a 75% level, consistent with a bandwagoning effect. For coverage rates above 75%, the treatment effects, albeit still positive, stop increasing and remain flat (or even decline). Our results suggest that, at higher coverage rates, free-riding behavior may partially crowd out bandwagoning effects of coverage rate messages. We also find significant heterogeneity of these effects depending on the individual perceptions of risks of infection and of the coverage rates.

Willingness, refusal and influential factors of parents to vaccinate their children against the COVID-19: A systematic review and meta-analysis

We aimed to estimate parents' willingness and refusal to vaccinate their children against the COVID-19, and to investigate the predictors for their decision. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We searched Scopus, Web of Science, Medline, PubMed, CINAHL and medrxiv from inception to December 12, 2021. We applied a random effect model to estimate pooled effects since the heterogeneity was very high. We used subgroup analysis and metaregression analysis to explore sources of heterogeneity. We found 44 studies including 317,055 parents. The overall proportion of parents that intend to vaccinate their children against the COVID-19 was 60.1%, while the proportion of parents that refuse to vaccinate their children was 22.9% and the proportion of unsure parents was 25.8%. The main predictors of parents' intention to vaccinate their children were fathers, older age of parents, higher income, higher levels of perceived threat from the COVID-19, and positive attitudes towards vaccination (e.g. children's complete vaccination history, history of children's and parents' vaccination against influenza, confidence in vaccines and COVID-19 vaccines, and COVID-19 vaccine uptake among parents). Parents' willingness to vaccinate their children against the COVID-19 is moderate and several factors affect this decision. Understanding parental COVID-19 vaccine hesitancy does help policy makers to change the stereotypes and establish broad community COVID-19 vaccination. Identification of the factors that affect parents' willingness to vaccinate their children against COVID-19 will provide opportunities to enhance parents' trust in the COVID-19 vaccines and optimize children's uptake of a COVID-19 vaccine.

Shared decision-making interventions: An overview and a meta-analysis of their impact on vaccine uptake

BACKGROUND

The interest in shared decision making (SDM) and the use of patient decision aids have increased significantly. Research indicates that this approach has benefits, and yet, implementation remains a challenge. To illustrate this development, we focus on vaccine hesitancy which has become a serious public health challenge during the COVID-19 pandemic. Various strategies have been used in healthcare, with limited success, to help patients overcome vaccine hesitancy. It is unclear whether SDM interventions can increase vaccination rates.

AIMS

Our aim was two-fold: to provide an overview of SDM and the use of patient decision aids and to determine the effect of SDM interventions on vaccine uptake.

METHODS

To provide an overview, we drew on our knowledge of the field and summarized the most recent systematic reviews. We examined the impact on vaccine hesitancy by searching for randomized controlled trials (RCTs) of SDM interventions, conducted a meta-analysis and calculated a pooled odds ratio. Additional outcomes were reported in a narrative synthesis.

RESULTS

SDM is viewed as the pinnacle of patient-centred care, supported by an ethical imperative and by empirical evidence of benefits. We found 10 RCTs that met our inclusion criteria. SDM interventions significantly increased vaccine uptake compared to control groups (odds ratio = 1.45; 95% confidence interval [1.17-1.80]; p < 0.01). Some RCTs also reported significantly decreased decisional conflict and increased decision confidence.

CONCLUSION

Future healthcare delivery systems will need to consider how to support the implementation of SDM. Interventions designed to facilitate this approach can represent a helpful, ethically defensible, strategy to increase vaccination rates.

Therapist disclosure to combat COVID-19 vaccine hesitancy: a narrative review

With the onset of the COVID-19 pandemic in 2019–2020 and the rapid development of vaccines to prevent this disease came a rise in interest around vaccine hesitancy. Naturally, methods of combatting vaccine hesitancy and increasing vaccination rates are of paramount importance. One such method is building upon the trust and openness of one’s relationship with their healthcare provider. Specifically, this paper examines how psychotherapist self-disclosure could facilitate effective health behaviors in patients, focusing on vaccines. Traditionally, mental health therapists have been encouraged to avoid self-disclosure of personal information due to the possibility of unbalancing or damaging the therapeutic relationship. However, research from medicine and other disciplines suggests that personal recommendation, self-disclosure of vaccination status, and expert encouragement may be effective methods of addressing vaccine hesitancy. In addition, recommendations for therapists in discussing vaccination and in working with vaccine-hesitant patients are provided.

Vaccine hesitancy in health-care providers in Western countries: a narrative review

INTRODUCTION

Vaccine hesitancy (VH) is a leading cause of suboptimal vaccine uptake rates worldwide. The interaction between patients and health-care providers (HCPs) is the keystone in addressing VH. However, significant proportions of HCPs, including those who administer vaccines, are personally and professionally vaccine-hesitant.

AREAS COVERED

This narrative review sought to characterize the nature, extent, correlates, and consequences of VH among HCPs. We included 39 quantitative and qualitative studies conducted in Western countries, published since 2015, that assessed VH among HCPs in general, for several vaccines. Studies were reviewed using the WHO 3Cs model - (lack of) confidence, complacency, and (lack of) convenience.

EXPERT OPINION

Despite the lack of validated tools and substantial heterogeneity in the methods used to measure VH among HCPs, this review confirms its presence in this population, at frequencies that vary by country, profession type, setting, and level of medical education. Lack of knowledge and mistrust in health authorities/pharmaceutical industry/experts were among its principal drivers. Improving the content about vaccination in HCPs' training programs, facilitating access to reliable information for use during consultations, and developing and validating instruments to measure HCPs' VH and its determinants are key to addressing VH among HCPs.

Listening to vaccine refusers

In bioethics vaccine refusal is often discussed as an instance of free riding on the herd immunity of an infectious disease. However, the social science of vaccine refusal suggests that the reasoning behind refusal to vaccinate more often stems from previous negative experiences in healthcare practice as well as deeply felt distrust of healthcare institutions. Moreover, vaccine refusal often acts like an exit mechanism. Whilst free riding is often met with sanctions, exit, according to Albert Hirschman's theory of exit and voice is most efficiently met by addressing concerns and increasing the quality and number of feedback channels. If the legitimate grievances responsible for vaccine refusal are not heard or addressed by healthcare policy, further polarization of attitudes to vaccines is likely to ensue. Thus, there is a need in the bioethics of vaccine refusal to understand the diverse ethical questions of this inflammable issue in addition to those of individual responsibility to vaccinate.

Association of community engagement with vaccination confidence and uptake: A cross-sectional survey in Sierra Leone, 2019

Background

The 2014-2016 Ebola epidemic disrupted childhood immunization in Sierra Leone, Liberia, and Guinea. After the epidemic, the Government of Sierra Leone prioritized community engagement to increase vaccination confidence and uptake. To support these efforts, we examined potential drivers of vaccination confidence and uptake in Sierra Leone.

Methods

We conducted a population-based household survey with primary caregivers of children in a birth cohort of 12 to 23 months in four districts with low vaccination coverage in Sierra Leone in 2019. Modified Poisson regression modeling with robust variance estimation was used to examine if perceived community engagement in planning the immunization program in the community was associated with vaccination confidence and having a fully vaccinated child.

Results

The sample comprised 621 age-eligible children and their caregivers (91% response rate). Half of the caregivers (52%) reported that it usually takes too long to get to the vaccination site, and 36% perceived that health workers expect money for vaccination services that are supposed to be given at no charge. When mothers were the decision-makers of the children's vaccination, 80% of the children were fully vaccinated versus 69% when fathers were the decision-makers and 56% when other relatives were the decision-makers. Caregivers with high confidence in vaccination were more likely to have fully vaccinated children compared to caregivers with low confidence (78% versus 53%). For example, caregivers who thought vaccines are 'very much' safe were more likely to have fully vaccinated children than those who thought vaccines are 'somewhat' safe (76% versus 48%). Overall, 53% of caregivers perceived high level of community engagement, 41% perceived medium level of engagement, and 6% perceived low level of engagement. Perceiving high community engagement was associated with expressing high vaccination confidence (adjusted prevalence ratio (aPR) = 2.60; 95% confidence interval (CI) = 1.67-4.04) and having a fully vaccinated child (aPR = 1.67; 95% CI = 1.18-2.38).

Conclusions

In these four low coverage districts in Sierra Leone, the perceived level of community engagement was strongly associated with vaccination confidence among caregivers and vaccination uptake among children. We have provided exploratory cross-sectional evidence to inform future longitudinal assessments to further investigate the potential causal effect of community engagement on vaccination confidence and uptake.

A qualitative insight into the perceptions and COVID-19 vaccine hesitancy among Pakistani pharmacists

A qualitative exploration of pharmacists’ perceptions regarding COVID-19 conspiracies and their willingness to get vaccinated. A semi-structured questionnaire guide was developed using ground theory to conduct in-depth interviews. A total of 36 participants gave consent for an audio-recorded interview. Results have shown that most of the respondents believed that SARS-CoV-2 is a natural virus, not man-made, that causes a disease just like other viruses and it is absurd to believe that the vaccine is being used by foreign powers for the implantation of microchips just to control humans. A general opinion thatwhich reflected from the in-depth interview is that the pharmaceutical companies may be hiding some important information on COVID-19 to promote the sale of their product. Some doubts on the reliability and trustworthiness on the COVID-19 vaccine safety and efficacy data were noticed among the respondents. Factors leading to COVID-19 vaccine hesitancy were adverse reaction, cost of COVID-19 vaccine, and limited data on safety and efficacy profile of COVID-19 vaccine. COVID-19 vaccine hesitancy among health professionals is a major hindrance to our current fight against COVID-19 pandemic. Findings of this study are alarming, and the stakeholders must consider this ongoing vaccination campaign as an opportunity to formulate a mechanism to ensure high vaccination rate among general public and healthcare providers in Pakistan.

KEY POINTS

What was already known?

According to World Health Organization (WHO), vaccine hesitancy is one of the ten major threats to global healthcare system and it is a major barrier to achieve herd immunity around the globe.

Pakistan has begun vaccinating its people in a systematic phase-wise manner under which the healthcare workers and elderly people are prioritized for vaccination.

Previous experience tells us that vaccine hesitancy is a major problem in Pakistan and it is better to understand perceptions of pharmacists about COVID-19 vaccine who are the primary source of information for most of general population.

What this study adds:

This study is first of its kind to explore vaccine hesitancy among Pakistani pharmacists and the results of this study show that majority of the participants were willing to get COVID-19 vaccine and few of them have even got themselves vaccinated at the start of vaccination campaign.

Many among the willing participants considered cost of vaccine, adverse reactions, limited data, safety, and efficacy as major hindrance to their decision to get vaccine.

Few participants were found highly vaccine-hesitant because of their staunch belief in the prevalent myths and rumors about COVID-19 vaccine.

Rapid Deployment of Multiple-Tactics to Address SARS-CoV-2 Vaccine Uptake in Healthcare Employees with a focus on Those Who Identify as Black, Indigenous, and People of Color (BIPOC)

Background

In the third quarter of 2021, government entities enacted vaccine requirements across multiple employment sectors, including healthcare. Experience from previous vaccination campaigns within healthcare emphasize the need to translate community modalities of vaccine outreach and education that partner with Black communities, Indigenous communities, and communities of Color stakeholders to increase vaccine confidence broadly.

Methods

This was an observational feasibility study conducted from August through October 2021 that deployed and measured the effect of a multimodal approach to increasing vaccine uptake in healthcare employees. Vaccine data were acquired through the Center for Disease Control Immunization Information Systems across Oregon and Washington. Rates of complete vaccination before the intervention were compared with rates after as a measure of feasibility of this intervention. These data were subdivided by race/ethnicity, age, gender, and job class. Complete vaccination was defined as completion of a 2-dose mRNA SARS-CoV-2 vaccine series or a 1-dose adenoviral vector SARS-CoV-2 vaccine.

Results

Overall preintervention and postintervention complete vaccination rates were 83.7% and 93.5%, respectively. Of those employees who identified as a certain race, black employees demonstrated the greatest percentage difference increase, 18.5% (preintervention, 72.1%; postintervention, 90.6%), followed by Hispanic employees, 14.1% (preintervention, 79.4%; postintervention, 93.5%), and employees who identify as 2 or more races, 13.9% (preintervention, 78.7%; postintervention, 92.6%)

Conclusions

We found that a multimodal approach to improving vaccination uptake in employees was feasible. For organizations addressing vaccine requirements for their workforce, we recommend a multimodal strategy to increase vaccine confidence and uptake.

Understanding how the Australian vaccine-refusal movement perceives itself

Public health responses to the vaccine-refusal (VR) movement are hindered by inadequate research about the movement's aims, identity and perceived value for its members. This study examined how members of the VR movement in Australia described the movement and what being part of it meant to them. Descriptions of the VR movement by 696 members from across Australia were collected between January and May in 2017 via an online survey. The data were analysed using thematic discourse analysis. Members' understandings of the movement and the beliefs underpinning these understandings were examined. Vaccine refusal was underpinned by distinct epistemic beliefs. Participants believed that mainstream vaccine promotion relies on dishonest communication of compromised research. They saw the VR movement as a science-based movement, researching both 'mainstream' and 'hidden' knowledge, promoting scientific values and advocating for better vaccine studies. Participants believed responsible parenting requires personally researching healthcare choices. Participants constructed the movement's identity in relation to common criticisms of vaccine refusal. These were discredited and repurposed to portray the movement as being brave and righteous. Participants believed people in the movement are astute, informed, responsible and courageous. They believed many members were impacted by vaccine-related harms, from which the movement now saves others. They saw themselves as fighting for an inconvenient truth that the mainstream ignores. Vaccine promotion needs to address the epistemic beliefs associated with vaccine refusal, yet these have been inadequately understood. Our findings contribute to understanding these beliefs. Furthermore, our findings suggest what messages targeting vaccine-refusing people should focus on. This may include acknowledging the significant effort that vaccine-refusing people invest in trying to protect their children, catering to vaccine-refusing people's high engagement and desire for detailed information, and avoiding stigmatising or confrontational vaccine-promotion strategies.

Exploring COVID-19 Vaccine Hesitancy Among Stakeholders in African American and Latinx Communities in the Deep South Through the Lens of the Health Belief Model

PURPOSE

The purpose of this study was to qualitatively explore perceptions related to COVID-19 vaccination intention among African American and Latinx participants and suggest intervention strategies.

APPROACH

Ninety minute virtual focus groups (N = 8), segmented by county, race and ethnicity were conducted with stakeholders from 3 vulnerable Alabama counties.

PARTICIPANTS

Participants (N = 67) were primarily African American and Latinx, at least 19 years, and residents or stakeholders in Jefferson, Mobile, and Dallas counties.

SETTING

Focus groups took place virtually over Zoom.

METHODS

The semi-structured guide explored perceptions of COVID-19, with an emphasis on barriers and facilitators to vaccine uptake. Focus groups lasted approximately 90 minutes and were audio recorded, transcribed, and analyzed by a team of 3 investigators, according to the guidelines of Thematic Analysis using NVivo 12. To provide guidance in the development of interventions to decrease vaccine hesitancy, we examined how themes fit with the constructs of the Health Belief Model.

RESULTS

We found that primary themes driving COVID-19 vaccine hesitancy, ordered from most to least discussed, are mistrust, fear, and lack of information. Additionally, interventions to decrease vaccine hesitancy should be multi-modal, community engaged, and provide consistent, comprehensive messages delivered by trusted sources.

Readability assessment of vaccine information: A systematic review for addressing vaccine hesitancy

OBJECTIVE

Vaccine hesitancy is a problem attracting growing attention and concern. Communication can be an effective tool to counteract vaccine hesitancy and promote optimal vaccine uptake. Readability has been recognized as one of the more important aspects of health communication for achieving good health literacy. We reviewed studies of readability assessment in the area of vaccine communication.

METHODS

We conducted a systematic literature search in September 2020, using four online databases (Medline, CINAHL, PsycArticles, and PsycINFO). We included studies that assessed the readability level of online and offline vaccine information materials.

RESULTS

We found 12 articles that were appropriate for inclusion. Ten of the studies were published after 2016. The readability levels of the majority of the materials assessed were found to be difficult and higher than 8th-grade level.

CONCLUSION

Readability assessments of vaccine information are scarce. The limited evidence shows that the readability level of vaccine information supplied by health care providers is more difficult to read than recommended. More studies on the readability of vaccine information are recommended.

PRACTICE IMPLICATIONS

Difficulty reading vaccine information may influence attitudes toward acceptance of or hesitancy to take vaccines. It is recommended that health care professionals use guidelines and tools to create easy-to-read vaccine information.