Face-to-face interventions for informing or educating parents about early childhood vaccination

Vaccine hesitancy educational interventions for medical students: A systematic narrative review in western countries

Physician recommendations can reduce vaccine hesitancy (VH) and improve uptake yet are often done poorly and can be improved by early-career training. We examined educational interventions for medical students in Western countries to explore what is being taught, identify effective elements, and review the quality of evidence. A mixed methods systematic narrative review, guided by the JBI framework, assessed the study quality using MERSQI and Cote & Turgeon frameworks. Data were extracted to analyze content and framing, with effectiveness graded using value-based judgment. Among the 33 studies with 30 unique interventions, effective studies used multiple methods grounded in educational theory to teach knowledge, skills, and attitudes. Most interventions reinforced a deficit-based approach (assuming VH stems from misinformation) which can be counterproductive. Effective interventions used hands-on, interactive methods emulating real practice, with short- and long-term follow-ups. Evidence-based approaches like motivational interviewing should frame interventions instead of the deficit model.

Effectiveness of chatbots in increasing uptake, intention, and attitudes related to any type of vaccination: A systematic review and meta-analysis

This systematic review and meta-analysis analyzed and summarized the growing literature on the effectiveness of chatbot-delivered interventions in increasing uptake, intention, and attitudes related to any type of vaccination. We identified randomized controlled studies (RCTs), quasi-experimental studies, and non-experimental studies from the following platforms: PubMed, Web of Science, MEDLINE, Global Health, APA PsycInfo, and EMBASE databases. A total of 12 eligible studies published from 2019 to 2023 were analyzed and summarized. In particular, one RCT showed that a chatbot-delivered tailored intervention was more effective than a chatbot-delivered non-tailored intervention in promoting seasonal influenza vaccine uptake among older adults (50.5% versus 35.3%, p = 0.002). Six RCTs were included in the meta-analysis to evaluate the effectiveness of chatbot interventions to improve vaccination attitudes and intentions. The pooled standard mean difference (SMD) of overall attitude change was 0.34 (95% confidence intervals [CI]: 0.13, 0.55, p = 0.001). We found a non-significant trivial effect of chatbot interventions on improving intentions of vaccination (SMD: 0.11, 95% CI: -0.13, 0.34, p = 0.38). However, further evidence is needed to draw a more precise conclusion. Additionally, study participants reported high satisfaction levels of using the chatbot and were likely to recommend it to others. The development of chatbots is still nascent and rooms for improvement exist.

Determinants of maternal adherence to child vaccination in jordan: A cross-sectional study

In the past few years, a significant decline in vaccination coverage has been noted, leading to measles outbreaks. Mothers' adherence or reluctance to undergo childhood immunization is a major contributing factor to a substantial population of children who remain unvaccinated or inadequately vaccinated. This study aimed to investigate adherence to children's vaccination by investigating mothers' personal and contextual factors in addition to knowledge and attitudes scores. A cross-sectional analytical design was employed, and data were collected from a sample of 533 mothers in Jordan between May and July 2023. The statistical analysis included descriptive analysis, t-test, ANOVA, and Pearson r correlation. The results demonstrated that adherence to vaccination was associated with several factors, including knowledge score (r = 0.33, p < 0.01), the ability to access and understand health information (r = 0.16, p < 0.01), income level (F = 11.88, p < 0.01), education level (F = 5.71, p < 0.01), employment (t = 2.41, p < 0.05), and working in a medical field (t = 4.5, p < 0.01). Scheffe post hoc analysis was performed to evaluate adherence outcomes according to the different categories of education and income levels. Mothers' adherence to vaccination needs improvement, with special attention given to contributing factors. Strategies should be developed to target mothers with low incomes and educational levels and limited ability to access and understand health information to enhance maternal knowledge and eventually adherence to children's vaccination.

Analyzing the usage of theories of change for routine immunization programs -- a review of impact evaluations from LMICs

BACKGROUND

In this article we analyzed the extent of the usage of Theories of Change (TOCs) and causal pathways in the evaluation of immunization programs to identify the challenges to generating evidence on how interventions improve immunization.

METHODS

We analyzed the use of the TOC in impact evaluations (IEs) of immunization interventions published after 2010, and its associated articles. The review includes studies from Evidence Gap Map and Yale review that were conducted in May and March of 2020, respectively. We synthesized data on six domains using NVIVO - program theory, context, assumptions, usage of TOC, use in evaluation, and description causal pathways.

RESULTS

Our review included 47 large-scale and 45 small-to medium-scale interventions. Of the included studies, 19% used a TOC, 56% described a causal pathway or used a conceptual diagram with varying degrees of detail, and 25% of the IEs did not provide any information on how their intervention was expected to affect change. Only 19 of the 92 IEs explicitly outlined any assumptions associated with the implementation of the interventions. Forty studies measured the outputs or intermediate outcomes leading to improved immunization coverage.

CONCLUSION

Future implementers and evaluators need to develop clear TOCs that are based on established theory and have clearly articulated the underlying assumptions. Large-scale health system strengthening initiatives implemented by governments, also need to build TOCs and integrate them into their results frameworks. Additionally, there is a need to combine both impact and process evaluations to understand the how context affects the causal pathways.

Vaccination status among children in an urban area and its association with risk factors and some parent health practices: A cross-sectional study

OBJECTIVE

The study aims to determine the vaccination status of children and evaluate the relationship between vaccination rates, vaccine attitudes, and some parental health practices.

DESIGN AND METHODS

This cross-sectional study was conducted with 674 mothers. Data were collected using a survey evaluating vaccine characteristics, some infant health practices, and The Public Attitude Toward Vaccination Scale-Health Belief Model. Chi-square test, independent samples t-test, and logistic regression analysis were used.

RESULTS

80.2% of children were fully vaccinated. The rate of non or under-vaccination was higher in the group that did not regularly undergo follow-up for 0-2-year-old children, did not fully have health screenings, did not use vitamin D and iron supplements, and used alternative medicine. Moreover, the duration of breast milk feeding, the transition to supplementary food, and the duration of vitamin D use in the non-fully vaccinated group were lower than in the fully vaccinated group (p < .05). The increase in maternal education period and severity and benefit attitude scores of vaccine attitude were the factors that decreased the rate of non-fully vaccination. The increase in barrier scores toward vaccines increased the rate of non or under-vaccination.

CONCLUSION

Mothers who have negative attitudes toward vaccination have negative behaviors in health practices and screenings on infant/child health.

The Delicate Situation of Childhood Vaccination: On the Dispreferredness of Soliciting Parents' Intent to Vaccinate

In the Netherlands, parents of newborns typically participate in two-, four-, and eight-week medical consultations to monitor their children's development and discuss vaccinations, which will not be administered before eight weeks. During these visits, healthcare professionals routinely ask parents if they intend to vaccinate their children (i.e. to participate in the National Immunization Program). Using Conversation Analysis, we examine 62 videotaped consultations and present two lines of evidence to argue that the sequence initiated by professionals wherein they solicit parents' intent to vaccinate is dispreferred. First, this action is routinely deferred by preliminary sequences. Second, when professionals eventually initiate this action (i.e. if it is not preempted by parents during pre-sequences), they orient to its dispreferred status, for example by highlighting benefactive details of vaccination. We discuss the possible existence of asymmetrical (initiator-sided) pre-sequences, why soliciting parents' vaccination intent might be dispreferred, and implications for the design of communication interventions.

Health service providers' views on barriers and drivers to childhood vaccination of FDMN/Rohingya refugees: a qualitative study in Cox's Bazar, Bangladesh

Background

Despite established vaccination programs, vaccine-preventable diseases persist among about 900,000 Forcibly Displaced Myanmar Nationals (FDMN)/Rohingya refugees in the world's largest refugee settlement in Bangladesh. Health service providers (HSPs) play a key role in the delivery of childhood vaccination programs. This study explored their views on individual and context barriers and drivers to childhood vaccination in this setting.

Methods

Informed by the theoretical framework of the Capability-Opportunity-Motivation-Behavior (COM-B) model for behavior change, this qualitative study collected data through eight focus group discussions (FGDs) with community health workers (CHWs) and vaccinators in selected camps with high or low vaccination coverage rates, and through 11 in-depth interviews (IDIs) with key informants working in strategic, management, and administrative roles.

Findings

Barriers and drivers were evident across all COM factors for HSPs and caregivers. Among HSPs, knowledge around vaccination acted both as a barrier and driver, while communication skills and confidence in vaccination served as drivers. Caregivers' lack of awareness of vaccination, concerns and mistrust were described as main barriers. Context barriers included information system deficiencies, family dynamics, HSPs' working conditions, and vaccination site accessibility. Context drivers included effective communication, mobilization, and incentives. Differences between high and low coverage camps in Cox's Bazar included variations in HSPs' knowledge, communication strategies, incentive use, and stakeholder collaboration.

Discussion

For better vaccination coverage in the camps, context-related changes regarding collaboration, health workforce and the use of incentives seem necessary. Caregivers' mistrust toward vaccination needs to be considered under the social and historical background of the Rohingya community, and further addressed with targeted communication and campaigning.

Development of Promising Interventions to Improve Human Papillomavirus Vaccination in a School-Based Program in Quebec, Canada: Results From a Formative Evaluation Using a Mixed Methods Design

BACKGROUND

Despite the availability of school-based human papillomavirus (HPV) vaccination programs, disparities in vaccine coverage persist. Barriers to HPV vaccine acceptance and uptake include parental attitudes, knowledge, beliefs, and system-level barriers. A total of 3 interventions were developed to address these barriers: an in-person presentation by school nurses, an email reminder with a web-based information and decision aid tool, and a telephone reminder using motivational interviewing (MI) techniques.

OBJECTIVE

Here we report on the development and formative evaluation of interventions to improve HPV vaccine acceptance and uptake among grade 4 students' parents in Quebec, Canada.

METHODS

In the summer of 2019, we conducted a formative evaluation of the interventions to assess the interventions' relevance, content, and format and to identify any unmet needs. We conducted 3 focus group discussions with parents of grade 3 students and nurses. Interviews were recorded, transcribed, and analyzed for thematic content using NVivo software (Lumivero). Nurses received training on MI techniques and we evaluated the effect on nurses' knowledge and skills using a pre-post questionnaire. Descriptive quantitative analyses were carried out on data from questionnaires relating to the training. Comparisons were made using the proportions of the results. Finally, we developed a patient decision aid using an iterative, user-centered design process. The iterative refinement process involved feedback from parents, nurses, and experts to ensure the tool's relevance and effectiveness. The evaluation protocol and data collection tools were approved by the CHU (Centre Hospitalier Universitaire) de Québec Research Ethics Committee (MP-20-2019-4655, May 16, 2019).

RESULTS

The data collection was conducted from April 2019 to March 2021. Following feedback (n=28) from the 3 focus group discussions in June 2019, several changes were made to the in-person presentation intervention. Experts (n=27) and school nurses (n=29) recruited for the project appreciated the visual and simplified information on vaccination in it. The results of the MI training for school nurses conducted in August 2019 demonstrated an increase in the skills and knowledge of nurses (n=29). School nurses who took the web-based course (n=24) filled out a pretest and posttest questionnaire to evaluate their learning. The rating increased by 19% between the pretest and posttest questionnaires. Several changes were made between the first draft of the web-based decision-aid tool and the final version during the summer of 2019 after an expert consultation of experts (n=3), focus group participants (n=28), and parents in the iterative process (n=5). More information about HPV and vaccines was added, and users could click if more detail is desired.

CONCLUSIONS

We developed and pilot-tested 3 interventions using an iterative process. The interventions were perceived as potentially effective to increase parents' knowledge and positive attitudes toward HPV vaccination, and ultimately, vaccine acceptance. Future research will assess the effectiveness of these interventions on a larger scale.

Interventions to increase vaccination in vulnerable groups: rapid overview of reviews

OBJECTIVE

Groups which are marginalised, disadvantaged or otherwise vulnerable have lower uptake of vaccinations. This differential has been amplified in COVID-19 vaccination compared to (e.g.) influenza vaccination. This overview assessed the effectiveness of interventions to increase vaccination in underserved, minority or vulnerable groups.

METHODS

In November 2022 we searched four databases for systematic reviews that included RCTs evaluating any intervention to increase vaccination in underserved, minority or vulnerable groups; our primary outcome was vaccination. We used rapid review methods to screen, extract data and assess risk of bias in identified reviews. We undertook narrative synthesis using an approach modified from SWiM guidance. We categorised interventions as being high, medium or low intensity, and as targeting vaccine demand, access, or providers.

RESULTS

We included 23 systematic reviews, including studies in high and low or middle income countries, focused on children, adolescents and adults. Groups were vulnerable based on socioeconomic status, minority ethnicity, migrant/refugee status, age, location or LGBTQ identity. Pregnancy/maternity sometimes intersected with vulnerabilities. Evidence supported interventions including: home visits to communicate/educate and to vaccinate, and facilitator visits to practices (high intensity); telephone calls to communicate/educate, remind/book appointments (medium intensity); letters, postcards or text messages to communicate/educate, remind/book appointments and reminder/recall interventions for practices (low intensity). Many studies used multiple interventions or components.

CONCLUSION

There was considerable evidence supporting the effectiveness of communication in person, by phone or in writing to increase vaccination. Both high and low intensity interventions targeting providers showed effectiveness. Limited evidence assessed additional clinics or targeted services for increasing access; only home visits had higher confidence evidence showing effectiveness. There was no evidence for interventions for some communities, such as religious minorities which may intersect with gaps in evidence for additional services. None of the evidence related to COVID-19 vaccination where inequalities of outcome are exacerbated.

PROSPERO REGISTRATION

CRD42021293355.

Identification of Spatial Clusters of Undervaccination Patterns Among Children Aged <24 Months Using Immunization Information System Data, Montana, 2015-2019

OBJECTIVE

Spatial clustering of undervaccination leads to increased risk of vaccine-preventable diseases. We identified spatial clustering of undervaccination patterns among children aged <24 months in Montana.

METHODS

We used Montana's immunization information system data to analyze deidentified vaccination records of children aged <24 months born from January 2015 through November 2017. We measured 3 outcomes that were not mutually exclusive: not completing the combined 7-vaccine series by age 24 months, having an undervaccination pattern indicative of parental hesitancy, and having an undervaccination pattern indicative of structural barriers to timely vaccination. Using geomasked residential addresses, we conducted separate Bernoulli spatial scans with a randomization P < .01 to identify spatial clusters consisting of ≥100 children for each outcome and calculated the relative risk of having the undervaccination pattern inside versus outside the cluster.

RESULTS

Of 31 201 children aged <24 months included in our study, 11 712 (37.5%) had not completed the combined 7-vaccine series by age 24 months, and we identified 5 spatial clusters of this outcome across Montana. We identified 4 clusters of undervaccination patterns indicative of parental vaccine hesitancy, all in western Montana. The cluster with the largest relative risk (2.3) had a radius of 23.7 kilometers (n = 762 children, P < .001). We also identified 4 clusters of undervaccination patterns indicative of structural barriers, with 3 of the largest clusters in eastern Montana.

CONCLUSION

In Montana, different strategies to increase routine and timely childhood vaccination are needed in distinct areas of this large and predominantly rural state. Immunization information system data can pinpoint areas where interventions to increase vaccination uptake are needed.

Developing a novel screening tool to address pediatric COVID-19 vaccine hesitancy at point of care

Many children are still not vaccinated against COVID-19, often attributed to rising pediatric vaccine hesitancy. To address this complex public health issue, interventions that uncover parental thinking at point of care are needed to help facilitate discussions in the exam room. The cognitive science framework of Rule Developing Experimentation helps distinguish how people think about day-to-day topics by presenting respondents with a systematic combination of messages that determines the ideas primarily driving their decisions. We hypothesized that Rule Developing Experimentation can empirically assess and identify parental mind-sets in deciding to vaccinate their children to prevent COVID-19. Artificial intelligence was also incorporated to more efficiently help formulate messages. Through an iterative process, surveying a total of 600 participants, three mind-sets emerged regarding the types of messages which parents believe would convince them to vaccinate their children to prevent COVID-19. These three mind-sets are summarized by the following phrases - "Covid is Serious," "Science Says Vaccine Works," and "Vaccine Returns Kids to Normalcy". Using these mind-sets, a simple six-question instrument (i.e., Personal Viewpoint Identifier) was then created to quickly discern at point of care a parent's mind-set surrounding pediatric COVID-19 vaccination. By quickly identifying a parent's mindset at point of care, providers can then utilize the results of the assessment to deliver individualized messaging to parents about the benefits of COVID-19 vaccination. A future study is planned to evaluate the impact of incorporating the Personal Viewpoint Identifier into routine pediatric care settings on COVID-19 vaccination rates.

Digital Gamification Tools to Enhance Vaccine Uptake: Scoping Review

BACKGROUND

Gamification has been used successfully to promote various desired health behaviors. Previous studies have used gamification to achieve desired health behaviors or facilitate their learning about health.

OBJECTIVE

In this scoping review, we aimed to describe digital gamified tools that have been implemented or evaluated across various populations to encourage vaccination, as well as any reported effects of identified tools.

METHODS

We searched Medline, Embase, CINAHL, the Web of Science Core Collection, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Academic Search Premier, PsycInfo, Global Health, and ERIC for peer-reviewed papers describing digital gamified tools with or without evaluations. We also conducted web searches with Google to identify digital gamified tools lacking associated publications. We consulted 12 experts in the field of gamification and health behavior to identify any papers or tools we might have missed. We extracted data about the target population of the tools, the interventions themselves (eg, type of digital gamified tool platform, type of disease/vaccine, type and design of study), and any effects of evaluated tools, and we synthesized data narratively.

RESULTS

Of 1402 records, we included 28 (2%) peer-reviewed papers and 10 digital gamified tools lacking associated publications. The experts added 1 digital gamified tool that met the inclusion criteria. Our final data set therefore included 28 peer-reviewed papers and 11 digital gamified tools. Of the 28 peer-reviewed papers, 7 (25%) explained the development of the tool, 16 (57%) described evaluation, and 2 (7%) reported both development and evaluation of the tool. The 28 peer-reviewed papers reported on 25 different tools. Of these 25 digital gamified tools, 11 (44%) were web-based tools, 8 (32%) mobile (native mobile or mobile-enabled web) apps, and 6 (24%) virtual reality tools. Overall, tools that were evaluated showed increases in knowledge and intentions to receive vaccines, mixed effects on attitudes, and positive effects on beliefs. We did not observe discernible advantages of one type of digital gamified tool (web based, mobile, virtual reality) over the others. However, a few studies were randomized controlled trials, and publication bias may have led to such positive effects having a higher likelihood of appearing in the peer-reviewed literature.

CONCLUSIONS

Digital gamified tools appear to have potential for improving vaccine uptake by fostering positive beliefs and increasing vaccine-related knowledge and intentions. Encouraging comparative studies of different features or different types of digital gamified tools could advance the field by identifying features or types of tools that yield more positive effects across populations and contexts. Further work in this area should seek to inform the implementation of gamification for vaccine acceptance and promote effective health communication, thus yielding meaningful health and social impacts.

Effective interventions for improving routine childhood immunisation in low and middle-income countries: a systematic review of systematic reviews

OBJECTIVE

An umbrella review providing a comprehensive synthesis of the interventions that are effective in providing routine immunisation outcomes for children in low and middle-income countries (L&MICs).

DESIGN

A systematic review of systematic reviews, or an umbrella review.

DATA SOURCES

We comprehensively searched 11 academic databases and 23 grey literature sources. The search was adopted from an evidence gap map on routine child immunisation sector in L&MICs, which was done on 5 May 2020. We updated the search in October 2021.

ELIGIBILITY CRITERIA

We included systematic reviews assessing the effectiveness of any intervention on routine childhood immunisation outcomes in L&MICs.

DATA EXTRACTION AND SYNTHESIS

Search results were screened by two reviewers independently applying predefined inclusion and exclusion criteria. Data were extracted by two researchers independently. The Specialist Unit for Review Evidence checklist was used to assess review quality. A mixed-methods synthesis was employed focusing on meta-analytical and narrative elements to accommodate both the quantitative and qualitative information available from the included reviews.

RESULTS

62 systematic reviews are included in this umbrella review. We find caregiver-oriented interventions have large positive and statistically significant effects, especially those focusing on short-term sensitisation and education campaigns as well as written messages to caregivers. For health system-oriented interventions the evidence base is thin and derived from narrative synthesis suggesting positive effects for home visits, mixed effects for pay-for-performance schemes and inconclusive effects for contracting out services to non-governmental providers. For all other interventions under this category, the evidence is either limited or not available. For community-oriented interventions, a recent high-quality mixed-methods review suggests positive but small effects. Overall, the evidence base is highly heterogenous in terms of scope, intervention types and outcomes.

CONCLUSION

Interventions oriented towards caregivers and communities are effective in improving routine child immunisation outcomes. The evidence base on health system-oriented interventions is scant not allowing us to reach firm conclusions, except for home visits. Large evidence gaps exist and need to be addressed. For example, more high-quality evidence is needed for specific caregiver-oriented interventions (eg, monetary incentives) as well as health system-oriented (eg, health workers and data systems) and community-oriented interventions. We also need to better understand complementarity of different intervention types.

Analysis of risk factor for pneumonia in children less than five years in Makassar

BACKGROUND

Pneumonia is one of the main causes of mortality in children less than five years worldwide and in Makassar City. The aim of this study was to investigate the risk factors for pneumonia in children less than five years in Makassar City.

MATERIALS AND METHODS

A case-control study design was used in this research. A total of 210 children with consent from the parents were included in this study, which consisted of 70 children's cases, and the data of the control group were taken by the random sampling method. All related data such as immunization record, nutritional status, birth body weight, vitamin A intake in the last six-month record, and parents' education, occupation, and monthly income were registered as independent and control variables. Data analysis was performed by the Chi-square and logistic regression model with a P value of 0.005 and odds ratio (OR) with a 95% confidence interval (CI).

RESULTS

Incomplete diphtheria-pertussis-tetanus-hepatitis B and Haemophilus influenzae type B (DPT-HB-Hib) immunization at the age of 2 months, 3 months, and 4 months, which had adjusted OR (AOR = 9,680; P = 0,001) and malnutrition condition (weight for age) (AOR = 5,486; P < 0,005), were associated with the incidence of pneumonia in children less than five years, whereas incomplete measles-rubella (P = 0,770), low birth weight history (P = 0,403), lack of vitamin A intake (P = 0,720), parents' education (P = 0,163), and presence of smoker inside the household (P =) were not associated with the incidence of pneumonia in children less than five years (P > 0.005) in Makassar City.

CONCLUSIONS

Incomplete DPT-HB-Hib immunization for three doses at the age of 2 months, 3 months, and 4 months and malnutrition were associated with pneumonia and the highest risk factors for developing pneumonia in children less than five years in Makassar City, Indonesia.

Empathic Engagement With the COVID-19 Vaccine Hesitant in Private Facebook Groups: A Randomized Trial

BACKGROUND

Vaccine misinformation has been widely spread on social media, but attempts to combat it have not taken advantage of the attributes of social media platforms for health education.

METHODS

The objective was to test the efficacy of moderated social media discussions about COVID-19 vaccines in private Facebook groups. Unvaccinated U.S. adults were recruited using Amazon's Mechanical Turk and randomized. In the intervention group, moderators posted two informational posts per day for 4 weeks and engaged in relationship-building interactions with group members. In the control group, participants received a referral to Facebook's COVID-19 Information Center. Follow-up surveys with participants (N = 478) were conducted 6 weeks post-enrollment.

RESULTS

At 6 weeks follow-up, no differences were found in vaccination rates. Intervention participants were more likely to show improvements in their COVID-19 vaccination intentions (vs. stay same or decline) compared with control (p = .03). They also improved more in their intentions to encourage others to vaccinate for COVID-19. There were no differences in COVID-19 vaccine confidence or intentions between groups. General vaccine and responsibility to vaccinate were higher in the intervention compared with control. Most participants in the intervention group reported high levels of satisfaction. Participants engaged with content (e.g., commented, reacted) 11.8 times on average over the course of 4 weeks.

CONCLUSIONS

Engaging with vaccine-hesitant individuals in private Facebook groups improved some COVID-19 vaccine-related beliefs and represents a promising strategy.

Contextualising missed opportunities for children's vaccination: A theory-informed qualitative study in primary care settings in Cape Town, South Africa

This study aimed to explore the contextual factors that may be associated with missed opportunities for vaccination (MOV) from the perspectives of healthcare providers and caregivers attending primary healthcare facilities in the Cape Town Metro Health District, South Africa. The ultimate goal of the assessment was to help inform the design and implementation of a contextually appropriate quality improvement programme targeted at reducing MOV in primary healthcare settings. We used a theory-informed exploratory qualitative research design involving focus group discussions with caregivers of children aged 0-23 months; and in-depth interviews of facility staff. A thematic template analysis approach, integrating the theoretical domains framework (TDF) and the capability, opportunity and motivation model of behavior (COM-B) was used to code and analyze the data. Three focus group sessions were conducted, each consisting of 5-8 caregivers and five in-depth interviews involving facility staff. Capability factors comprised caregivers' knowledge, attitude and behavior toward children's immunization. Opportunity factors included the organization of immunization services, long waiting time, vaccine stock out, staff shortage and health workers' attitude, knowledge and capability to assess children's immunization status and needs. Motivation factors included optimism and beliefs about immunization, fear of vaccine-preventable diseases and immunization safety concerns. This study identified important caregiver-, provider- and health system-related factors, which influence immunization outcomes; offering useful contextual insights for informing quality improvement strategies for reducing MOV at primary healthcare level.

Worldwide Child Routine Vaccination Hesitancy Rate among Parents of Children Aged 0-6 Years: A Systematic Review and Meta-Analysis of Cross-Sectional Studies

Routine vaccine hesitancy is a major global health challenge observed in over 190 countries worldwide. This meta-analysis aims to determine the worldwide prevalence of routine vaccination hesitancy among parents of children aged 0-6. An extensive search was conducted in four scientific databases: PubMed, Scopus, Web of Science, and the Cochrane Library. Studies were included if they reported hesitancy related to WHO-recommended routine immunizations for children under 7 years of age. A single-arm meta-analysis was performed using the OpenMeta[Analyst] software. An initial search retrieved 5121 articles, of which only 23 publications, involving 29,131 parents, guardians, and caregivers from over 30 countries met the inclusion criteria and quality assessment. The cumulative prevalence of parental vaccine hesitancy was found to be 21.1% (95% CI = 17.5-24.7%, I2 = 98.86%, p < 0.001). When stratifying the prevalence of vaccine hesitancy per WHO region, significant variations were observed, ranging from 13.3% (95% CI = 6.7-19.9%, I2 = 97.72%, p < 0.001) in the Region of the Americas to 27.9% (95% CI = 24.3-31.4%) in the Eastern Mediterranean region. The study findings highlight the need for healthcare providers and governments to develop and improve comprehensive programs with communication strategies to reduce parental vaccine hesitancy.

How to increase and maintain high immunization coverage: Vaccination Demand Resilience (VDR) framework

BACKGROUND

Resilience in vaccination demand is ever more critical as the COVID-19 pandemic has increased our understanding of the importance of vaccines on health and well-being. Yet timid demand for COVID-19 vaccines where available and reduced uptake of routine immunizations globally further raise the urgent need to build vaccination resilience. We demonstrate the complexity of vaccination demand and resilience in a framework where relevant dimensions are intertwined, fluid, and contextual.

METHODS

We developed the Vaccination Demand Resilience (VDR) framework based on a literature review on vaccination demand and expert consultation. The matrix framework builds on three main axes: 1) vaccination attitudes and beliefs; 2) vaccination seeking behavior; and 3) vaccination status. The matrix generated eight quadrants, which can help explain people's levels of vaccination demand and resilience. We selected four scenarios as examples to demonstrate different interventions that could move people across quadrants and build vaccination resilience.

RESULTS

Incongruence between individuals' attitudes and beliefs, vaccination behavior, and vaccination status can arise. For example, an individual can be vaccinated due to mandates but reject vaccination benefits and otherwise avoid seeking vaccination. Such incongruence could be altered by interventions to build resilience in vaccination demand. These interventions include information, education and communication to change individuals' vaccination attitudes and beliefs, incentive programs and reminder-recalls to facilitate vaccination seeking, or by strengthening healthcare provider communications to reduce missed opportunities.

CONCLUSIONS

Vaccination decision-making is complex. Individuals can be vaccinated without necessarily accepting the benefits of vaccination or seeking vaccination, threatening resilience in vaccination demand. The VDR framework can provide a useful lens for program managers and policy makers considering interventions and policies to improve vaccination resilience. This would help build and sustain confidence and demand for vaccinations, and help to continue to prevent disease, disability, and death from vaccine-preventable diseases.

Multicomponent interventions to improve routine childhood vaccine uptake in low and middle-income countries: a scoping review protocol

INTRODUCTION

Vaccine coverage remains inequitable globally. Many systematic reviews have looked at the effectiveness of strategies to improve vaccine uptake; however, these reviews frequently lack data from low and middle-income countries (LMICs), where evidence of cost-effective strategies is most valuable. This is partly because reviews often exclude non-randomised, observational or unpublished evaluations that are common in LMICs. Many reviews also exclude multicomponent interventions due to challenges isolating the effect of each component. A comprehensive mapping of multicomponent interventions implemented in LMICs would increase the visibility of studies excluded from systematic reviews and improve comparability of future evaluations by providing guidance for researchers on evaluation frameworks. This scoping review aims to identify, compare and summarise the properties and evaluation methods of multicomponent interventions to improve uptake of routine childhood vaccines in LMICs, and to assess the strengths and limitations of evaluation frameworks applied.

METHODS AND ANALYSIS

This review will be conducted using the Joanna Briggs Institute methodology for scoping reviews and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews guidelines. We will search the following databases: MEDLINE, Embase, PubMed, Cochrane, Eldis and Global Health (CAB Direct), Global Index Medicus, 3ie Portal, Google Scholar, COnnecting REpositories, and reference lists. One author will screen titles and abstracts and extract data from included articles using a pretested data extraction template. Uncertainties will be resolved through discussion with another author. Only studies published in English will be included for full review. We will assess the practicability, applicability, sensitivity and specificity of the evaluation frameworks used and present results using descriptive statistics, summary tables and charts.

ETHICS AND DISSEMINATION

Ethics approval is not required. The review will be submitted as part of a doctoral thesis, presented at conferences and published in peer-reviewed journals.

STUDY REGISTRATION

https://osf.io/7r84g.

Physicians' knowledge, attitude and perceptions towards vaccine-hesitant parents: a cross-sectional study

OBJECTIVES

Research has shown that physicians are encountering an increase in vaccine-hesitant parents (VHPs) numbers. This study examined physicians' vaccination knowledge, vaccine-related discussions with VHPs, beliefs about and responses to vaccine hesitancy, and challenges faced while discussing immunization with VHPs.

METHODS

This cross-sectional, descriptive study was performed at King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia, in September 2020. The data were collected through a questionnaire distributed via email. The sample comprised 90 physicians who routinely treat children and reported they frequently have appropriate vaccine discussions when encountering VHPs.

RESULTS

Ninety participants (59% were females) completed the questionnaire. Of these, 37.8% were from family medicine, 7.8% from primary care, and 54.4% from paediatrics. The most discussed topics were vaccine necessity, reasons for vaccine refusal, and vaccine safety. Seventeen participants (18.8%) reported being extremely confident, and (42.2%) were confident in their vaccine-specific knowledge. Regarding confidence in communication skills, 22.2% reported being extremely confident and (45.6%) were confident. Determinants of higher confidence in the knowledge and communication skills were physician age (p = 0.001 and p = 0.0001, respectively), years of practice (p = 0.002 and (p = 0.005), and patients seen per workday (p = 0.0001 and p = 0.024). Other factors such as physician sex (p = 0.062), the field of practice (p = 0.329), and hours of work per week (p = 0.061) were not significantly different. Forty-six (51%) physicians sometimes find it challenging to conduct appropriate vaccine-related discussions because of having too many other issues to discuss during the consultation. Furthermore, 53 (59%) participants agreed/strongly agreed that parental refusal to vaccinate would raise suspicions of negligence. On the other hand, 59 (65%) disagreed/strongly disagreed that parental refusal of vaccines is a parental right. Participants expressed the need to refer VHPs to a specialised advisory clinic with excellent experience and negotiation skills to overcome the challenges.

CONCLUSION

Vaccine safety and necessity are the topics of most concern to VHPs, and a knowledgeable physician with competent communication skills is critical in responding to such situations. This study highlights the most reported barriers to successful vaccine-related discussions. It raises underlying ethical principles such as parental autonomy and the need to train physicians in VHPs. To train physians for succucful vaccine counceling of VHPs.

Tackling Vaccine Hesitancy and Increasing Vaccine Willingness Among Parents of Unvaccinated Children in Austria

Objectives: In autumn 2021, there was a surge of COVID-19 infections in Austria, and vaccination coverage stagnated at a below-average level compared to the rest of Europe. Surveys showed that both children and adolescents were the main drivers of the rising infection rates and that vaccination numbers were particularly low in this age group. This was due to widespread vaccination skepticism and hesitancy among parents of unvaccinated children and adolescents. Methods: Here, we describe a novel intervention concept that allowed us to efficiently tackle parental vaccine hesitancy. We designed an intervention series that followed a reproducible format based on online face-to-face seminars in groups of a maximum of twenty people. Each seminar included an anonymous online questionnaire for internal quality control. Moreover, we assessed the motives of parental vaccine hesitancy and asked participants to rate subjective vaccine willingness for their children on a scale of zero to ten. Results: Within 8 weeks, more than 580 people participated in the seminar series. We found that concerns about the side effects of the vaccine were the predominant motive of vaccination hesitancy among the study population. Overall, the intervention could successfully increase the median parental vaccination willingness of participants from a score of five to eight. We identified tree hesitancy motives (distrust towards the pharmaceutical industry, the government, or feelings of restriction from personal freedom) that were associated with below-average vaccination willingness and significant lower increase. Conclusion: With this study we analyzed motives driving COVID-19 vaccination hesitancy among parents of unvaccinated children and reasons of parents to restrain their children from getting vaccinated. The intervention method described here, could effectively address individual concerns on a personal level while at the same time reach a large number of people across geographical and language barriers. Thereby we could significantly increase subjective vaccination willingness of the participants. Our approach is easy to apply, highly cost-effective, and can be used to tackle any kind of medical misinformation.

Parental perceptions, attitudes, and beliefs regarding vaccination of children aged 0-5 years: A qualitative study of hill-tribe communities, Thailand

The widespread availability and use of vaccines have tremendously reduced morbidity and deaths related to infectious diseases globally. However, in hill-tribe communities in Northern Thailand, vaccination rates remain low, and there is limited literature on parental perceptions, attitudes, and beliefs about vaccination for children under five years of age. We conducted a qualitative study employing semi-structured interviews to understand parents' perceptions, attitudes, and beliefs about vaccinations. A purposive sample was used to recruit participants. Data were analyzed using thematic analysis. 74 hill-tribe parents (14 Akha, 11 Hmong, 12 Lahu, 13 Lisu, 12 Karen, and 12 Yao) were interviewed. Four themes emerged from the interviews: 1) traditional beliefs, and practices 2) traumatic experiences, 3) lack of information and effective communication, and 4) trust and support from the community. Findings highlight that it is crucial to build trust by providing knowledge, appropriate information, and advice about vaccinations in order to improve vaccine coverage in children under five years of age in the hill-tribe context.

Motives and attitudes of parents toward HPV vaccination: Results from the initial period of HPV vaccine rollout in Serbia

Human papillomavirus (HPV) infection is one of the most common viral infections in sexually active population worldwide, and is the main cause of cervical cancer, which is the fourth most common cancer among women. Serbia ranks third in incidence and mortality rate of cervical cancer in Europe. We conducted a cross-sectional study considering parents' motivation for the HPV vaccination of their children. Statistical analysis included descriptive statistics and a logistic regression model. We found that the strongest motive was "Recommendation from paediatrician" (20.2%), followed by the attitude that HPV vaccine protects against cancers in different localization (15.4%), the motive "It is better to vaccinate a child than expose them to potential risk of HPV infection" (13.3%) and "Feeling anxiety due to a possible infection and cancer in the child" (13.1%). For those parents that vaccinated their child for some other strongest motive, reasons like "Vaccine is free of charge", "Recommendation from friends and family" and motive "My child received all obligatory vaccines, so I want to receive this one as well", were significantly more frequently selected. In the group where paediatricians' recommendation was not a motive for accepting the HPV vaccine, the largest percentage of parents (89.6%) selected motive "HPV vaccine protects against cancers in different localization" and the motive "It is better to vaccinate a child than expose them to potential risk of HPV infection" (78.1%). Paediatrician's recommendation is very important for parents' decision to vaccinate, however, other motives also influenced and had significance in making the parents' decision to vaccinate their children against HPV. Encouraging trust in public health authorities in Serbia, highlighting the advantages of the HPV vaccine and further encouraging healthcare workers to give stronger recommendations can increase the HPV vaccine uptake. Finally, we provided the basis to create more targeted messages that will empower parents to vaccinate their children.

Do social media interventions increase vaccine uptake?

Introduction

The Italian mass COVID-19 vaccination campaign has included children aged 5-11 years as part of the target population since December 2021. One of the biggest challenges to vaccine uptake was vaccine hesitancy among parents and children's caregivers. Primary care pediatricians (PCPs), as the first point of contact between the National Health Service (NHS) and parents/caretakers, initiated various communication strategies to tackle this hesitancy. This study aims to evaluate the impact of a PCP-led social media intervention and a digital reminder service (DRS) on parental hesitancy regarding vaccinating their 5-11-year-old children against COVID-19.

Methods

A prospective cohort study was designed, and the chosen target populations were parents and caretakers of children aged 5-11 years. Two PCP cohorts were recruited. The first group received a social media intervention and a DRS; while the second group did not. Both cohorts had access to traditional face-to-face and telephone-based counseling. The vaccination coverage rate in the two groups was evaluated.

Results

A total of 600 children were enrolled. The exposed cohort (277 patients) received social media intervention, DRS, and counseling options (face-to-face and telephone-based), whereas the non-exposed cohort (323 patients) received only counseling options. In total, 89 patients from the exposed cohort did not receive any dose of the COVID-19 vaccine (32.5%), 165 were fully immunized (59.5%), and 23 received only one dose (8.5%). A total of 150 non-exposed patients did not receive any dose of the COVID-19 vaccine (47%), 147 were fully immunized (45.5%), and 24 only received one dose (7.4%). The difference between the two groups was statistically significant (chi square = 11.5016; p = 0.0006).

Conclusion

Social media and DRS interventions had a positive impact on vaccine uptake and may be helpful in tackling vaccine hesitancy. Better-designed studies are needed to corroborate these findings.

Vaccine-hesitant families are more susceptible to verbal communication messaging

OBJECTIVES

Our survey aims to highlight parents' and healthcare workers' opinions and hesitations regarding children's vaccination, identify the main factors influencing these opinions, and assess the impact of hesitations on immunisation for children, included in the National Immunisation Programme in Lithuania.

METHODS

We used the questionnaire developed by the European Academy of Paediatrics Research in Ambulatory Settings Network (EAPRASnet). This questionnaire is designed to assess attitudes toward vaccination. The study involved parents raising children aged 1-4 years and primary healthcare providers (paediatricians, family doctors and nurses).

RESULTS

We analysed the completed questionnaires from a total of 329 parents (142 fathers, 187 mothers) and 386 medical personnel (150 physicians, 236 nurses). Most parents expressed positive opinions about vaccines (> 8 points out of 10 possible), with older parents exhibiting more favourable attitudes. Compared to mothers, fathers showed more criticism regarding the information provided by physicians (p = 0.04). Family doctors and paediatricians were more supportive of vaccination than nurses and homoeopaths (p < 0.001). Parents and healthcare providers with higher education showed statistically significantly stronger opinions about the benefits of vaccines than those with lower education levels (p = 0.01 for parents, p < 0.001 for physicians and nurses). The Internet was identified as the primary source of negative information for both parents (69.6%) and healthcare providers (86%). However, verbal information received from medical staff during patient consultations or informal conversations among colleagues had the greatest impact on parents' opinions (17.3%) and medical personnel (35.5%).

CONCLUSIONS

Confidential conversations with physicians and nurses remain the most trustworthy sources of information and influential factors shaping opinions. The Internet serves as the primary source of inaccurate information about vaccinations for both parents and medical professionals, although verbal information from primary healthcare providers has a more significant impact on vaccination attitudes. Discrepancies in basic education and specific knowledge about vaccination within the same family can pose additional obstacles to child vaccination.

The effectiveness of hepatitis B vaccine in toddlers based on the five-year period national basic health research (Riskesdas 2007, 2013 and 2018) in Indonesia

Background

Hepatitis B is a viral infection that has a high prevalence in Indonesia. The Ministry of Health of Indonesia has conducted a national vaccination program for hepatitis B. In order to evaluate the success of the hepatitis B vaccination in Indonesia, a community study based on basic health research (Riskesdas) was performed nationwide since 2007 for five year period in 2007, 2013, and 2018.

Methods

Further statistical analysis was performed specifically for the children under 59 months old (toddlers) immunized in both urban and rural areas in 2007, 2013, and 2018 based on certain characteristics by examining antibodies against HBsAg (anti-HBs), IgG antibodies against the core antigen (HBcAb), surface antigen (HBsAg) of hepatitis B virus (HBV). The data obtained from the data management laboratory of Ministry of Health, Indonesia, was analyzed with Bivariate analysis with continuity correction chi-square or Pearson chi-square using Stata software version 16.

Results

This study showed an increase in hepatitis B coverage of complete immunization (30% in 2007, 60.3% in 2013, and 57% in 2018), which was also influenced by mothers' level of education (Pearson chi-square , p ¡ 0.05) and access to health service points within 30 minutes (OR = 1.3-2.8, p ¡ 0.05). The trend of the percentage of immune status (anti-HBs) was increased (41.8% in 2007; 56.1% in 2013; and 79.1% in 2018). The higher anti-HBs was found in complete hepatitis B immunization status (OR = 1.5-2, p ¡ 0.05) and in good nutritional status (p ¡ 0.05). However, the anti-HBs was found decreased with increasing age (p ¡ 0.05). The trend of positive HBcAb (exposure to HBV infection) showed a decrease gradually of almost ten times from 2007 (8.6%-13.5%) compared to 2013 (2.6%-11.1%) and 2018 (1.1%-2%). Urban areas were at higher risk of hepatitis B exposure (OR = 1.4-2.2) than rural areas (OR = 0.37-0.80). The HBsAg data were only available in 2013 and 2018. Riskesdas data analysis showed the prevalence of hepatitis B (HBsAg) was lower in complete immunization status than that in incomplete one (p ¡ 0.05), but with an increase from 3.9% (2013) to 9.3% (2018), possibly due to inappropriate implementation of birth dose immunization or a vaccine-escape mutant from the HBV variants.

Conclusions

The effectiveness of hepatitis B vaccine obtained from the three Riskesdas periods in Indonesia showed an improvement, with an increase in immune status, reduced exposure to HBV and a lower prevalence of hepatitis B in children with complete vaccination. However, there is still an increase in hepatitis B infection, especially in urban areas. Therefore, a long-term evaluation of immunization coverage especially ensuring that the initial dose of immunization was given within the first 24 h of birth, HBsAg and HBcAb, nutritional status, genomic surveillance of HBV, and other aspects of program quality evaluation are needed to ensure that elimination efforts have been implemented properly.

Role of Psychosomatic Symptoms in COVID-19 Vaccine Hesitancy

Vaccination against COVID-19 is one of the highly effective preventative strategies to reduce morbidity and mortality associated with COVID-19 infection. The rapid approval of COVID-19 vaccination due to the raging pandemic, media coverage, anti-vaccination groups, and concerns about adverse effects associated with vaccination has given rise to COVID-19 vaccine hesitancy. Current evidence suggests that psychosomatic and nocebo-related adverse effects account for a significant proportion of common adverse effects following COVID-19 vaccination. The most common adverse effects are headache, fatigue, and myalgia, which are highly prone to nocebo effects. In our review article, we discuss the role of psychosomatic and nocebo effects in COVID-19 vaccination-related hesitancy, predictors of such effects, and strategies to reduce vaccine hesitancy. General education regarding psychosomatic and nocebo effects and specialized education for at-risk populations may reduce psychosomatic and nocebo-related adverse effects following COVID-19 vaccination, ultimately reducing hesitancy.

Interventions addressing maternal and child health among the urban poor and homeless: an overview of systematic reviews

BACKGROUND

Inequalities in access to and utilization of maternal and child health (MCH) care are hampering progress on the path to achieving the Sustainable Development Goals. In a number of Low- and Middle-Income Countries (LMICs) population subgroups at disproportionate risk of being left behind are the urban poor. Within this neglected group is the further neglected group of the homeless. Concomitantly, a number of interventions from the antenatal period onward have been piloted, tested, and scaled in these contexts. We carried out an overview of systematic reviews (SRs) to characterize the evidence around maternal and child health interventions relevant to urban poor homeless populations in LMICs.

METHODS

We searched Medline, Cochrane Library, Health Systems Evidence and EBSCOhost databases for SRs published between January 2009 and 2020 (with an updated search through November 2021). Our population of interest was women or children from urban poor settings in LMICs; interventions and outcomes corresponded with the World Health Organization's (WHO) guidance document. Each SR was assessed by two reviewers using established standard critical appraisal checklists. The overview was registered in PROSPERO (ID: CRD42021229107).

RESULTS

In a sample of 33 high quality SRs, we found no direct relevant evidence for pregnant and lactating homeless women (and children) in the reviewed literature. There was a lack of emphasis on evidence related to family planning, safe abortion care, and postpartum care of mothers. There was mixed quality evidence that the range of nutritional interventions had little, unclear or no effect on several child mortality and development outcomes. Interventions related to water, sanitation, and hygiene, ensuring acceptability of community health services and health promotion type programs could be regarded as beneficial, although location seemed to matter. Importantly, the risk of bias reporting in different reviews did not match, suggesting that greater attention to rigour in their conduct is needed.

CONCLUSION

The generalizability of existing systematic reviews to our population of interest was poor. There is a clear need for rigorous primary research on MCH interventions among urban poor, and particularly homeless populations in LMICs, as it is as yet unclear whether the same, augmented, or altogether different interventions would be required.

Development of PIVOT with MI: A motivational Interviewing-Based vaccine communication training for pediatric clinicians

Delay or refusal of childhood vaccines is common and may be increasing. Pediatricians are parents' most trusted source for vaccine information, yet many struggle with how to communicate with parents who resist recommended vaccines. Evidence-based communication strategies for vaccine conversations are lacking. In this manuscript, we describe the development and perceived usefulness of a curriculum to train clinicians on a specific vaccine communication strategy as part of the PIVOT with MI study, a cluster randomized trial testing the effectiveness of this communication strategy on increasing childhood vaccination uptake among 24 pediatric practices in Colorado and Washington. The communication strategy is based on the existing evidence-based communication strategies of a presumptive format for initiating vaccine conversations and use of motivational interviewing if hesitancy persists. Focus groups and semi-structured interviews with pediatric clinicians helped inform the development of the training curriculum, which consisted of an introductory video module followed by 3 training sessions. Between September 2019 and January 2021, 134 pediatric clinicians (92 pediatricians, 42 advanced practice providers) participated in the training as part of the PIVOT with MI study. Of these, 92 % viewed an introductory video module, 93 % attended or viewed a baseline synchronous training, 82 % attended or viewed a 1st refresher training, and 77 % attended or viewed a 2nd refresher training. A follow-up survey was administered August 2020 through March 2021; among respondents (n = 100), >95 % of participants reported that each component of the training program was very or somewhat useful. These data suggest that the PIVOT with MI training intervention is a useful vaccine communication resource with the potential for high engagement among pediatric clinicians.

Comparing the effect of parental education via both lecture and film upon vaccination uptake for children under one year of age: A cluster randomized clinical trial

BACKGROUND AND AIM

Vaccination is the most cost-effective action in preventing infectious diseases. Despite Iran's success in high vaccination coverage, in some areas there is a delay in vaccination. The aim of this study was to determine and compare the effect of education on immunization via lecture and film upon parental delay in vaccination uptake for children under 12 months of age.

METHODS

A multicentre cluster-randomized clinical trial with comprehensive urban health centres (CUHCs) in Shooshtar city, Khuzestan province, Iran as the unit of randomization was conducted. Overall, 8 CUHCs were randomized to receive education either via film (n = 165) or lecture (n = 164). In order to assign CUHCs to two groups, a simple random sampling method of coin tossing was used. Parents with children under 12 months and with a history of delayed vaccination were included in the study. Consecutive sampling was performed until the number needed for the cluster was reached. Interventions were delivered in small groups of 5-8 participants. Demographical data and clinical histories were collected from parents directly via a personal characteristic's questionnaire. Clinical data was extracted from vaccination records, the child's vaccine card and the vaccine information registration system. Statistical analyses of intervention effects were performed as per-protocol analysis.

RESULTS

In terms of individual characteristics and vaccine information significant differences between the two groups were only observed in relation to the parent of the participant, the child's gender, the number of children in the family, and timely injection of the vaccine in the previous child (p < 0.05). The chance of delay in vaccination after the intervention, without and considering the effect of intervening variables was 78 % and 74 % higher in the lecture group than in the film group, respectively (OR = 1.786, CI = 1.152-2.774 vs AOR = 1.743, CI = 1.011-3.007). Overall, 37.6 % of children in the film-based education group and 51.8 % of children in the lecture-based education group received their next vaccine with a delay of more than 7 days.

CONCLUSION

Education delivered via film can reduce the delay in vaccination more effectively. These findings, along with those of other studies conducted around the world suggest that multimedia education should be considered more widely in the field of education in children's vaccination.

Attitudes, hesitancy, concerns, and inconsistencies regarding vaccines reported by parents of preschool children

OBJECTIVE

This study aimed to assess attitudes, concerns, information and knowledge about vaccines among parents of preschool children attending kindergartens in a city in the interior of São Paulo, Brazil, using a self-administered questionnaire.

METHODS

Cross-sectional, questionnaire-based study of knowledge and attitudes regarding vaccination among parents of children aged up to 72 months from public and private schools, between 2018 and 2019.

RESULTS

Among the 2,528 questionnaires, 1,261 were answered and grouped by respondents' educational level. According to information, 96.6% of the children were up to date with vaccines. The prevalence of vaccine hesitancy was 5.0%. The lower the educational level, the lower was the income, the larger the number of household members, and the greater the lack of knowledge about vaccines. The higher the educational level, the lower was the vaccine hesitancy, and the greater the dissatisfaction with the information received.

CONCLUSIONS

Generally, parents consider vaccines to be important for preventing diseases and to be safe, with their benefits outweighing the risks. Positive comments were accompanied by doubts, concerns, hesitancy, and inconsistencies. The level of educational attainment makes a difference in the access to information, medical care provided by pediatricians, and the feeling of obligation to vaccinate. Parents have vaccinated and still intend to vaccinate their children, but ensuring adequate levels of vaccination coverage will be a post-pandemic challenge.

Determinants of basic childhood vaccination coverage in European and OECD countries

Vaccination coverage varies between countries and over time. Using official databases, we extracted data on 50 national-level immunization, socio-economic, demographic, healthcare, and cultural factors, and the uptake of the third dose of diphtheria toxoid, tetanus toxoid, and pertussis vaccines (DTP3) and the first dose of measles-containing vaccines (MCV1) for 61 countries between 1990 and 2019. The main branch of the analysis included all covariates, while a secondary branch excluded life-expectancy and child mortality. The statistical analysis was completed in three stages: a variable-selection stage via random forests; multilevel multiple imputation for missing data in the reduced dataset; and generalized estimating equations (GEE) over all imputed datasets with pooled results. Less than 20 covariates were retained after variable-selection. Among a relatively small number of statistically significant (p-value <.05) effects in the pooled GEE results of our main branch, under-5 mortality and long-term orientation culture showed negative associations with both uptake outcomes and GDP per capita a positive association. For MCV1, whether a second dose was integrated into routine immunization appeared as the overall strongest negative correlate. In the secondary analytical branch, results were largely consistent, with a few additional statistically significant effects emerging, mainly related to immunization and healthcare system characteristics. These insights improve our understanding of the main factors influencing vaccine uptake, some of which are broadly contextual (e.g., GDP, socio-cultural factors), requiring bespoke vaccine program approaches, in order to maximize childhood vaccine uptake over time.

Pilot study to determine effect of an altruism intervention focusing on herd immunity to enhance influenza vaccination rates

OBJECTIVE

A prospective, single-arm clinical trial was conducted to evaluate an altruism-tailored educational intervention to improve parental attitudes and vaccine uptake in vaccine-hesitant parents.

METHODS

Vaccine-hesitant parents at two primary care sites, spanning two influenza seasons from 2020 to 2021 were provided an intervention (spoken and written communication) which highlighted altruistic benefits of accepting the seasonal influenza vaccine to optimize herd immunity to help protect pediatric cancer patients. Eligible parents included those with children eligible for the seasonal influenza vaccine, those who were proficient in English, and those with scores on the adjusted Vaccine Hesitancy Scale (aVHS) suggesting vaccine hesitancy (score ≥ 3). Enrollees completed a demographic questionnaire, underwent the educational intervention, and repeated the aVHS. Vaccination status at that visit was assessed. The primary outcome was change in aVHS scores obtained pre- and post-intervention. Influenza vaccine acceptance, along with demographic information, were also analyzed.

RESULTS

We enrolled 510 parents of influenza vaccine eligible children and identified 73 vaccine-hesitant parents. There was an overall trend toward lower aVHS score, with a mean change in hesitancy score of -0.4 (P < 0.01). 43/73 (58.9 %) of the cohort experienced a positive effect toward a lower aVHS score, and 27/73 (37.0 %) of vaccine hesitant subjects became non-hesitant on the aVHS. Several demographic characteristics were associated with vaccine hesitancy in the screening population: educational level lower than bachelor's degree (p = 0.03), household income < 400 % of federal poverty level (p < 0.01), unmarried (p = 0.02), and identifying with a political affiliation other than Democrat (p < 0.01). However, no demographic characteristics were significantly associated with an individual becoming non-hesitant. Our altruism-tailored communication approach carried the largest positive impact on the altruism-specific question on the aVHS, decreasing the post-intervention response value by nearly 25 % (P < 0.01).

CONCLUSIONS

Our altruism-tailored communication approach significantly improved attitudes regarding childhood influenza vaccine among vaccine-hesitant parents.

CLINICALTRIALS

gov Identifier: NCT04568590.

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.

Methods of Current Practice: Qualitative Analysis of Intervention Strategies Utilized by Vaccine Waiver Educators in Michigan

By enacting administrative rule 325.176 (12), Michigan added a vaccine education component as a precondition to granting vaccine waivers to vaccine-hesitant parents wishing to file a nonmedical vaccine exemption for their school-aged child. The purpose of the study was to identify best practices for reaching vaccine-hesitant parents during face-to-face vaccine education sessions conducted by vaccine waiver educators in Michigan. This study utilized qualitative descriptive content analysis of semi-structured phone interviews with vaccine waiver educators from local health departments (LHDs) in Michigan. Participants were vaccine waiver educators who were employed by a local health department in Michigan and had conducted at least 30 vaccine waiver education sessions. Strategies, resources, and techniques identified by educators as beneficial included using and providing information from a variety of sources, compiling their own educational materials, creating a positive experience, holding personalized sessions, and streamlining exemption and vaccination sessions. However, unexpected themes that emerged from the interviews revealed that vaccine waiver educators need additional training in discussing vaccine ingredients with parents, handling religious vaccine exemption requests, and assessing the role of schools. Implementing successful vaccine education interventions targeting vaccine-hesitancy is crucial to public health. Charging LHDs with overseeing vaccine education via a face-to-face discussion is a novel intervention strategy, the effective implementation of which may inform vaccine education intervention nationwide and may even be translated into international contexts and prove useful to current COVID-19 vaccination efforts.

Perceptions of Healthcare Workers (HCWs) towards childhood immunization and immunization services in Fiji: a qualitative study

Introduction

Childhood immunization has been globally recognized as the single most effective strategy in preventing childhood diseases and mortality. The perceptions of healthcare workers are important as their behavior and attitudes influence parental decision–making process. This research aimed to explore the factors that influence healthcare workers’ experience and perceptions about delivering childhood immunization in Fiji.

Materials and methods

A qualitative study was conducted in three randomly selected health centers in Suva, Fiji from March 1st to April 5th, 2021. Five focus group discussions were conducted with healthcare workers who were chosen purposively, had worked in the health center for at least 6 months and included either gender. Those that did not consent or did not meet the inclusion criteria were excluded. The interviews were guided by semi–structured open–ended questionnaire and were recorded into a digital voice recorder. The data were coded, sorted, and then categorized into themes, and transcribed onto Microsoft Word. Thematic analysis was utilized to sort the key phrases from the recorded interviews.

Results

There were a total of 22 participants for the focus group discussions, with their ages ranging from 25 to 51 years, included 3 medical officers, 1 nurse practitioner and 18 registered nurses. Three major themes emerged, which included: healthcare worker factors, parental factors and health system factors. Subthemes identified from the healthcare worker factors were worker knowledge and attitudes. The subtheme for parental factors that emerged were defaulters, parental attitudes, perceived behavior and religious beliefs. For health system factors the subthemes were service delivery, registration, infrastructure, staff turnover, staff training and changes to the immunization schedule.

Conclusion

Some of the perceived barriers reported by the healthcare workers were parental religious beliefs, parental knowledge and attitude, social or physical factors (finances, transportation, childcare and work conflicts), access to health services, immunization services and policies, hours of operation, waiting time and missed opportunities. Health workers acknowledged that they have an important role to play in immunization as they are the source of information and motivation for parents. Further studies are needed to be conducted nationally to determine the perceptions of healthcare workers towards immunization and how the services can be improved on a national level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03665-9.

Promoting Physical Activity among Workers: A Review of Literature and Future Directions on Developing Theory-Based Interventions

Insufficient physical activity (PA) has been identified as a leading risk factor for premature and all-cause death, as well as non-communicable diseases. Employees, especially those with low occupational PA, are more vulnerable to physical inactivity, and studies in this population are scarce. However, employees may receive benefits for both health and work productivity from PA. Therefore, well-designed behavior change studies to promote PA in employees are urgently needed, especially during the COVID-19 pandemic. Literature was searched before 30 July 2022, and updated evidence was summarized. This review elaborates on the evidence related to insufficient PA and further provides an overview of theory-based interventions for promoting PA. Evidence indicates that intervention mapping (IM) was a useful tool to develop, implement, and evaluate behavior change interventions. Based on the IM framework, reviewing the theory- and evidence-based change methods and delivery modes, and further identifying the research gaps and limitations of existing interventions could provide promising suggestions and directions for development of well-founded interventions promoting PA among employees. The updated knowledge base for developing future interventions may boost efficacy and provide firm conclusions for researchers in this area.

Parental Attitudes Towards Vaccination Against COVID-19 in China During Pandemic

Purpose

The Chinese government has authorized the emergency use of an inactivated vaccine for COVID-19 in children and adolescents aged 3 to 17 years. This study aimed to investigate parents' attitudes towards vaccinating their children against COVID-19 and influencing factors.

Patients and Methods

Through an online questionnaire survey, we collected self-reported children's demographic characteristics, physical conditions and parents' attitudes towards COVID-19 vaccination for children. The parents in the unwilling group received online consultation about the benefits and risks of COVID-19 vaccine and were asked to complete the questionnaire again.

Results

A total of 868 participants were recruited from July 2021 to August 2021 in Nanjing, China. Overall, 76.0% of parents were willing to accept vaccination for children. Parents' willingness increased with children's age (P=0.018) and height (P=0.034), but decreased if the children fell sick within previous one month (P=0.030). Most of the unwilling parents gave a higher score to the risk of vaccination (53.76 VS 40.18). Unsafety (63.8%) and unfamiliarity (24.0%) were their major concerns. After consultation with a health worker, 24% of the unwilling parents turned willing.

Conclusion

Children's age and recent physical condition are related to parents' attitudes towards vaccination for children against COVID-19. The major concerns of parents are unsafety and unfamiliarity. Parents view health workers as a reliable source of vaccine information. A successful consultation with health workers to understand the benefits and risks of vaccination can increase parents' willingness. This study provides insight into parents' attitudes towards vaccination for children against COVID-19 in China and related influencing factors. Our findings could be referenced in establishing policies for vaccinating children against COVID-19 in China.

A quality improvement study: Optimizing pneumococcal vaccination rates in children with cochlear implants

Children with cochlear implants are at increased risk of invasive pneumococcal disease, with national and international guidelines recommending additional pneumococcal vaccines for these children. This study aimed to examine the pneumococcal immunization status and rate of invasive pneumococcal disease in children with cochlear implants at a tertiary paediatric hospital over a 12-year period. Additionally, the impacts of vaccination reminders and a dedicated immunization clinic on pneumococcal vaccination rates were assessed. This quality improvement study included 200 children who had received a cochlear implant through the Children's Hearing Implant Program at a tertiary paediatric hospital servicing the state of Western Australia. The majority of children (88%) were not up to date with additionally recommended pneumococcal vaccinations. Over the 12-year study period, 2% of children developed invasive pneumococcal disease associated with cochlear implant infections. Generic and personalized electronic immunization reminders improved pneumococcal vaccine up-take in this paediatric cochlear implant setting from 12% (19/153) at baseline to 49% (75/153, p < 0.0001) post implementation. The value of a nurse-led dedicated immunization clinic was also demonstrated with all children (42/42, 100%) up to date with Prevenar13 and the majority (34/42, 81%) up to date with Pneumovax23 post initiation of this referral pathway. These data support the expansion of this model to other medically-at-risk paediatric groups that have been highlighted consistently to be under-vaccinated.

Analysis on vaccine hesitation and its associated factors among parents of preschool children in Songgang Street, Shenzhen

China has the largest number of vaccinated population around the world. However, there has been few research on the prevalence and associated factors of vaccine hesitation among parents of preschool children. Therefore, we conducted this study to evaluate the status of vaccine hesitation and its associated factors among children’s parents. A cluster random sampling method was adopted to select six community health service centers in Shenzhen, and parents of preschool children who were immunized in the vaccination outpatient department of the selected community health centers were surveyed using a structured self-administered questionnaire. Vaccine hesitation was assessed by the Parent Attitudes about Childhood Vaccines (PACV) scale. A multiple linear regression analysis was used to assess the associated factors for vaccine hesitance among children's parents. A total of 1025 parents (response rate, 93.18%) filled out the questionnaires. The average score of vaccine hesitancy was 43.37 (SD = 10.34) points. 23.61% of parents wanted children to get all the recommended shots, 53.76% of them did not believe that many of the illnesses shots prevent were severe, and 75.41% of them could not guarantee the information they receive about shots. The results of multiple linear regression showed that the number of children in the family (β = −0.93, 95% CI: −1.31 to 0.54), health status of the child (β = 0.47, 95% CI: 0.07 to 0.87), education level of the parents (Father: β = −0.84, 95%CI: −1.37 to 0.31; Mother: = −1.59, 95%CI:−2.13 to −1.05), and annual family income (β = 1.64, 95%CI: 1.13–2.16) were significantly associated with vaccine hesitation. The average score of parents' vaccine hesitation in Shenzhen was 43.37. The results showed that the number of children in the family, health status of the children, education level of the parents and annual family income were important factors associated with the parents' vaccine hesitation.

Missed Opportunities for Vaccination and Associated Factors among Children Attending Primary Health Care Facilities in Cape Town, South Africa: A Pre-Intervention Multilevel Analysis

Despite the substantial efforts at ensuring universal access to routine immunisation services among children in South Africa, major gaps in immunisation coverage remain. This study assessed the magnitude of missed opportunities for vaccination (MOV) and associated factors among children aged 0–23 months attending primary health care (PHC) facilities in Cape Town. We used multilevel binomial logistic regression models to explore individual and contextual factors associated with MOV, with children aged 0–23 months at Level 1, nested within PHC facilities (Level 2). A total of 674 children and their caregivers were enrolled. MOV prevalence was 14.1%, ranging from 9.1% to 18.9% across sub-districts. Dose-specific MOV prevalence was highest for the second dose of measles vaccine (9.5%) and lowest for the first dose of rotavirus vaccine (0.6%). The likelihood of a child experiencing MOV was significantly associated with caregivers’ low level of education (Odds ratio (OR) = 3.53, 95% credible interval (CrI): 1.13–11.03), recent receipt of immunisation messages (OR = 0.46, 95%CrI: 0.25–0.87), shared immunisation decision making by both parents (OR = 0.21, 95%CrI: 0.07–0.62) and health facility staff number (OR = 0.18, 95%CrI: 0.06–0.61). The burden of MOV among children in Cape Town is influenced by individual and contextual factors, which provide important opportunities for quality improvement and broader strategies to improve routine immunisation service delivery.

Effect of a web-based cervical cancer survivor story on the willingness and behavioral change for Human Papillomavirus Vaccination among Japanese parents with at least one daughter aged 11 to 18 years old: Randomized Controlled Trial

Background

Providing adequate information to parents who have children eligible for human papillomavirus (HPV) vaccination is essential to overcoming vaccine hesitancy in Japan, where the government recommendation has been suspended. However, prior trials assessing the effect of brief educational tools have shown only limited effects on increasing the willingness of parents to vaccinate their daughters.

Objective

The aim of this trial is to assess the effect of a cervical cancer survivor’s story on the willingness of parents to get HPV vaccination for their daughters.

Methods

In this double-blinded, randomized controlled trial (RCT) implemented online, we enrolled 2175 participants aged 30-59 years in March 2020 via a webpage and provided them with a questionnaire related to the following aspects: awareness regarding HPV infection and HPV vaccination, and willingness for HPV vaccination. Participants were randomly assigned (1:1) to see a short film on a cervical cancer survivor or nothing, stratified by sex (male vs female) and willingness for HPV vaccination prior to randomization (yes vs no). The primary endpoint was the rate of parents who agreed for HPV vaccination for their daughters. The secondary endpoint was the rate of parents who agreed for HPV vaccination for their daughters and the HPV vaccination rate at 3 months. The risk ratio (RR) was used to assess the interventional effect.

Results

Of 2175 participants, 1266 (58.2%) were men and 909 (41.8%) were women. A total of 191 (8.8%) participants were willing to consider HPV vaccination prior to randomization. Only 339 (15.6%) participants were aware of the benefits of HPV vaccination. In contrast, 562 (25.8%) participants were aware of the adverse events of HPV vaccination. Although only 476 (21.9%) of the respondents displayed a willingness to vaccinate their daughters for HPV, there were 7.5% more respondents in the intervention group with this willingness immediately after watching the short film (RR 1.41, 95% CI 1.20-1.66). In a subanalysis, the willingness in males to vaccinate daughters was significantly higher in the intervention group (RR 1.50, 95% CI 1.25-1.81); however, such a difference was not observed among females (RR 1.21, 95% CI 0.88-1.66). In the follow-up survey at 3 months, 1807 (83.1%) participants responded. Of these, 149 (8.2%) responded that they had had their daughters receive vaccination during the 3 months, even though we could not see the effect of the intervention: 77 (7.9%) in the intervention group and 72 (8.7%) in the control group.

Conclusions

A cervical cancer survivor’s story increases immediate willingness to consider HPV vaccination, but the effect does not last for 3 months. Furthermore, this narrative approach to parents does not increase vaccination rates in children eligible for HPV vaccination.

Trial Registration

UMIN Clinical Trials Registry UMIN000039273; https://tinyurl.com/bdzjp4yf

Changing Perspectives on Pediatric Human Papillomavirus (HPV) Vaccination among Dental Students and Residents Reveals Recent Increase in Vaccine Hesitancy

This study was a retrospective analysis of previously collected anonymous survey data regarding vaccine awareness, beliefs, and knowledge among dental (DMD) students and postgraduate (PG) residents. The protocol for this study was approved by the Institutional Review Board (IRB) as exempt. A total of 341 responses were collected from n = 293 DMD students and n = 48 PG residents. Although most respondents agreed that vaccines were necessary, safe, and effective, over the past 4 years (2017-2020) a growing percentage of respondents disagreed. In addition, although most respondents disagreed that there are too many required vaccines, vaccines can make you sick, or are dangerous, a growing percentage of respondents now agreed with these statements. Finally, although most respondents were aware of the HPV vaccine, recently a growing percentage of both students and residents reported they had insufficient information about this vaccine. These results provide novel insights into recent changes in attitudes and beliefs regarding vaccination among this population. Moreover, analysis of these shifts in attitudes and knowledge about HPV vaccination suggests that curricular integration of vaccine research and hesitancy may be needed to answer these questions in a supportive learning environment that fosters critical thinking and evidence-based practice and decision making.

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.

The Need for Health Education and Vaccination-Importance of Teacher Training and Family Involvement

The health emergency due to COVID-19 has highlighted the importance of vaccination and its impact on social welfare. Inequalities have surfaced that affect the most vulnerable and those millions of children do not receive the necessary vaccines. Health education becomes a fundamental resource for citizens to access universal rights. One thousand people from 76 countries on five continents participated in this research in 2019–2020, from the health, education, and economic sectors. A descriptive cross-sectional study with a quantitative design was used. The instrument used was a correctly validated questionnaire: VACUNASEDUCA. The objectives were to reflect on the adequacy of teacher training and their awareness for the proper use of vaccines and to analyze the knowledge of parents about the consequences of vaccination. The results demonstrate the importance of teacher training and health education, with positive involvement of the family. The most favorable group is female, under 30 years, from the European continent, with a very high Human Development Index (HDI), and from the education sector. In conclusion, it is noted that, within the framework of the fourth industrial revolution, education must be configured with innovative approaches and tools, making it necessary to intervene in the context considering their cultural characteristics and promoting healthy lifestyle habits.

Factors that influence parents' and informal caregivers' views and practices regarding routine childhood vaccination: a qualitative evidence synthesis

BACKGROUND

Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations, for several potential reasons. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services; for instance, because of poor quality health services, distance from a health facility, or lack of money. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents' views and practices around childhood vaccination, and why some parents may not accept vaccines for their children, is still limited. This synthesis links to Cochrane Reviews of the effectiveness of interventions to improve coverage or uptake of childhood vaccination.

OBJECTIVES

- Explore parents' and informal caregivers' views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of routine childhood vaccination. - Develop a conceptual understanding of what and how different factors reduce parental acceptance of routine childhood vaccination. - Explore how the findings of this review can enhance our understanding of the related Cochrane Reviews of intervention effectiveness.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, and three other databases for eligible studies from 1974 to June 2020.

SELECTION CRITERIA

We included studies that: utilised qualitative methods for data collection and analysis; focused on parents' or caregivers' views, practices, acceptance, hesitancy, or refusal of routine vaccination for children aged up to six years; and were from any setting globally where childhood vaccination is provided.

DATA COLLECTION AND ANALYSIS

We used a pre-specified sampling frame to sample from eligible studies, aiming to capture studies that were conceptually rich, relevant to the review's phenomenon of interest, from diverse geographical settings, and from a range of income-level settings. We extracted contextual and methodological data from each sampled study. We used a meta-ethnographic approach to analyse and synthesise the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane Reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We integrated the findings of this review with those from relevant Cochrane Reviews of intervention effectiveness. We did this by mapping whether the underlying theories or components of trial interventions included in those reviews related to or targeted the overarching factors influencing parental views and practices regarding routine childhood vaccination identified by this review.

MAIN RESULTS

We included 145 studies in the review and sampled 27 of these for our analysis. Six studies were conducted in Africa, seven in the Americas, four in South-East Asia, nine in Europe, and one in the Western Pacific. Studies included urban and rural settings, and high-, middle-, and low-income settings. Many complex factors were found to influence parents' vaccination views and practices, which we divided into four themes. Firstly, parents' vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents' vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turn strengthened their views and practices around vaccination. Thirdly, parents' vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parents' vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, 'neoliberal logic', suggests that many parents, particularly from high-income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, 'social exclusion', suggests that some parents, particularly from low- and middle-income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. Many of the overarching factors our review identified as influencing parents' vaccination views and practices were underrepresented in the interventions tested in the four related Cochrane Reviews of intervention effectiveness.

AUTHORS' CONCLUSIONS

Our review has revealed that parents' views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic. We have provided a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting. The themes and concepts developed through our review could serve as a basis for gaining this understanding, and subsequent development of interventions that are potentially more aligned with the norms, expectations, and concerns of target users.

Understanding parents' views toward the newly enacted HPV vaccine school entry policy in Puerto Rico: a qualitative study

BACKGROUND

The Human papillomavirus vaccine (HPV) is an essential tool for the prevention of HPV-related cancers. In Puerto Rico, the Secretary of Health established a school entry requirement of at least one dose of HPV vaccination in girls and boys aged 11 and 12 years, taking effect in August 2018. Our study aimed to examine parents' and guardians' views of unvaccinated children about the process of implementation of the new HPV vaccination school entry policy in Puerto Rico and identify potential barriers and facilitators related to the implementation of this requirement.

METHODS

During April through November 2019, we conducted three focus groups (n = 12) and eight in-depth semi-structured interviews with parents of children aged 11 and 12 who had not yet initiated the HPV vaccine series. The interview topics addressed were: perception of vaccination, HPV vaccine and it is inclusion as new school entry requirement practice, procedure of the sources of information, influencers, and willingness to change. The interviews were recorded and transcribed by our staff members. We identified emergent themes through thematic analysis.

RESULTS

The participants' perspective on the HPV vaccine school requirement was mixed. Lack of information of the HPV vaccines and lack of communication about the school-entry requirement were the themes most mentioned in the interviews. Moreover, previous negative experiences from friends or family members and adverse effects deterred some participants from vaccinating their kids. We discussed barriers in the process of soliciting an exemption.

CONCLUSION

Most barriers mentioned by study participants are modifiable. Information about the HPV vaccine mandate's implementation and educational materials regarding HPV vaccine safety need to be provided to address parents' concerns related to the vaccine's side effects. Schools (teachers, principal directors, and administrative staff), the government, and parent organizations need to be part of these efforts. This multilevel approach will help to improve disseminating information about HPV vaccination to clarify doubts and misinformation among parents.