Barriers to and facilitators of early childhood immunization in rural areas of the United States: a systematic review of the literature

Rotavirus vaccine dose-two dropout and its associated factors among children who received rotavirus vaccine dose-one in Sub-Saharan African countries: A multilevel analysis of the recent demographic and health survey

Rotavirus is the most common cause of diarrhea in children worldwide. In 2016, rotavirus infection resulted in 258 173 300 episodes of diarrhea and 128 500 child deaths in the globe. The study aimed to assess the magnitude of Rotavirus vaccine dose-two dropout and associated factors among children who received rotavirus vaccine dose-one in sub-Saharan African countries. The appended and most recent demographic and health survey (DHS) dataset of 17 sub-Saharan African countries was used for data analysis. A total of 73,396 weighted samples were used. Factors associated with the outcome variable were considered significant if their p-values were ≤ .05 in the multilevel mixed-effect logistic regression model. The overall Rotavirus vaccine dose-two dropouts was 10.77% (95% CI 10.55%, 11.00%), which ranged from 2.77% in Rwanda to 37.67% in Uganda. Being younger, late birth order, having difficulty accessing health facilities, having no media exposure, having no work, having home delivery, having no antenatal follow-up, and having no postnatal checkup were factors significantly associated with the outcome variable. The overall Rotavirus vaccine dose-two dropout was higher in sub-Saharan African countries which implies that vaccine dropout is still a great issue in the region. Special attention should be given to those mothers who are young, who have no work, who give birth at home, who experienced difficulty in accessing health facilities, and late birth orders. Furthermore, targeted interventions should be considered for improving access and utilization of media, antenatal care, and postnatal care services.

Exploring Parental Attitudes and Perceptions Regarding Childhood Vaccinations in Greece: A Study Within the Framework of the National Health Examination Survey (EMENO)

AIM

Vaccinations have reduced illnesses and mortality rates globally, yet negative attitudes and uncertainty about them hinder their acceptability and efficacy. The study aims to document Greek parents' immunization perceptions and risk factors.

METHODS

Spanning 2014-2017, 447 parents (68% mothers) who participated in the Greek Health Examination Survey EMENO (National Survey of Morbidity and Risk Factors) completed an interview-delivered questionnaire. Attitudes were categorized into three groups: absolutely positive, positive, and negative. Absolutely positive attitudes included positive responses to all five statements in favor of vaccination and negative responses to the two statements against vaccination. Negative attitudes included positive responses to either one or both statements against vaccination and negative responses to all five statements in favor of vaccination.. All other participants were categorized as having a positive attitude. Skepticism towards vaccinations was classified into skeptical and non-skeptical groups based on responses to five statements implying uncertainty or skepticism. Participants were considered skeptical if they provided positive responses to at least three of these statements, and non-skeptical if they had none or up to two positive responses. The statistical analysis accounted for the study design whereas inverse probability weighting was used to adjust for non-response and multiple imputations were employed to impute missing values. The components of parental attitude and vaccine skepticism were identified using weighted multinomial logistic regression and logistic regression, respectively.

RESULTS

In total, 16.6% were classified as having absolutely positive attitudes towards vaccinations whereas 42.1% were skeptical of vaccines. Of all participants, 96.0% agreed that vaccinations are essential for their child's well-being and adhere to scientific recommendations. However, concerns were also mentioned, with 26.2% worrying about potential adverse effects, and 21.6% believing it is better to acquire immunity through illness rather than vaccination. Positive participants, compared to absolutely positive ones, were more likely to be of Greek origin (adjusted relative rate ratio (aRRR): 3.35; 95% CI: 1.53-7.30) and living in semi-urban areas (aRRR: 4.84; 95% CI: 1.77-13.29). Negative participants, in contrast, were more likely to have higher education (aRRR: 2.98; 95% CI: 1.05-8.44) but also to live in semi-urban areas (aRRR: 6.43; 95% CI: 1.69-24.56). Furthermore, parents of Greek origin had significantly higher odds of being skeptical towards vaccination (adjusted Odds Ratio (aOR): 2.86; 95% CI: 1.36-5.98), while married or cohabiting parents had lower odds of being skeptical compared to single parents (aOR: 0.60; 95% CI: 0.35-1.06).

CONCLUSIONS

While parents in this study recognize the importance of childhood immunizations, there is a widespread presence of negative attitudes and skepticism that can have a detrimental impact on vaccination rates.

A Psychometric Study of the Arabic Version of the "Searching for Hardships and Obstacles to Shots (SHOT)" Instrument for Use in Saudi Arabia

Vaccines are considered one of the top 10 public health achievements of the 20th century and the most cost-effective public health intervention to overcome diseases and disease-associated mortality. This study translated the "Searching for Hardships and Obstacles to Shots" (SHOT) instrument from English to Arabic and conducted a psychometric evaluation of the Arabic version to measure parental barriers to childhood immunization. The cross-sectional study utilized multistage cluster random sampling to recruit parents visiting 70 primary health centers in Jizan. Scale translation and cultural adaptation were used to translate the SHOT survey into Arabic. The survey revealed that the best-factor model was a one-factor solution for "barriers to child immunization." The first principal component explained the highest variance (56.22%), and subsequent components explained decreasing percentages of variance. The third principal component explained the decreased variance (4.61%), and subsequent components explained the decreasing percentages of variance. The overall reliability (determined by Cronbach's alpha) was 0.96. The strong internal consistency of the Arabic version of the SHOT instrument (as indicated by the high Cronbach's alpha coefficients) indicates that researchers and practitioners can confidently use this scale to measure parents' attitudes toward and perceptions of vaccinations. Furthermore, the study results will help policymakers develop programs or interventional initiatives to overcome these barriers.

Individual and Geospatial Determinants of Health Associated With School-Based Human Papillomavirus Immunization in Alberta: Population-Based Cohort Study

BACKGROUND

Human papillomavirus (HPV) infection causes nearly all cervical cancer cases and is a cause of anogenital and oropharyngeal cancers. The incidence of HPV-associated cancers is inequitable, with an increased burden on marginalized groups in high-income countries. Understanding how immunization status varies by material and social deprivation, health system, and geospatial factors is valuable for prioritizing and planning HPV immunization interventions.

OBJECTIVE

The objective of this study was to describe school-based HPV immunization rates by individual and geospatial determinants of health in Alberta, Canada.

METHODS

Health administrative data for male and female individuals born in 2004 in Alberta were used to determine HPV immunization status based on age and the number of doses administered in schools during the 2014/2015-2018/2019 school years. Immunization status and its relationship with material and social deprivation and health system factors were assessed by a logistic regression model. Geospatial clustering was assessed using Getis-Ord Gi* hot spot analysis. Mean scores of material and social deprivation and health system factors were compared between hot and cold spots without full HPV immunization using independent samples t tests. A multidisciplinary team comprising researchers and knowledge users formed a co-design team to design the study protocol and review the study results.

RESULTS

The cohort consisted of 45,207 youths. In the adjusted model, the odds of those who did not see their general practitioner (GP) within 3 years before turning 10 years old and not being fully immunized were 1.965 times higher (95% CI 1.855-2.080) than those who did see their GP. The odds of health system users with health conditions and health system nonusers not being fully immunized were 1.092 (95% CI 1.006-1.185) and 1.831 (95% CI 1.678-1.998) times higher, respectively, than health system users without health conditions. The odds of those who lived in areas with the most material and social deprivation not being fully immunized were 1.287 (95% CI 1.200-1.381) and 1.099 (95% CI 1.029-1.174) times higher, respectively, than those who lived in areas with the least deprivation. The odds of those who lived in rural areas not being fully immunized were 1.428 times higher (95% CI 1.359-1.501) than those who lived in urban areas. Significant hot spot clusters of individuals without full HPV immunization exist in rural locations on the northern and eastern regions of Alberta. Hot spots had significantly worse mean material deprivation scores (P=.008) and fewer GP visits (P=.001) than cold spots.

CONCLUSIONS

Findings suggest that material and social deprivation, health system access, and rural residency impact HPV immunization. Such factors should be considered by public health professionals in other jurisdictions and will be used by the Alberta co-design team when tailoring programs to increase HPV vaccine uptake in priority populations and regions.

Impact of COVID-19 Pandemic on Routine Childhood Immunization Programs in Indonesia: Taking Rural and Urban Area into Account

Background

To date, the primary global concern has revolved around addressing the COVID-19 pandemic. However, there is a growing awareness of the pandemic's secondary impacts on critical aspects of healthcare, such as childhood immunization programs.

Objective

This study aims to assess the impact of the COVID-19 pandemic on childhood immunization programs in Indonesia, with a specific focus on performance disparities between rural and urban areas. It considers factors like access, utilization, and program workload.

Methods

Data were collected from primary health cares (PHCs) in two regions in West Java Province, Indonesia, representing rural and urban areas. A descriptive analysis was conducted to compare vaccination coverage, drop-out rates, and the ratio of vaccinators per dose from 2019 to 2021 in 40 and 22 PHCs for rural and urban areas, respectively. A general linear model was employed to evaluate the differences in these parameters over the three consecutive years.

Results

The results indicate fluctuations in vaccine coverage over the three years, with the most significant impact observed in 2020, particularly in rural areas. Statistical analysis revealed a significant difference in routine immunization coverage, drop-out rates, and vaccinator ratios between rural and urban areas from 2019 to 2021 (p<0.05). In 2021, both rural and urban areas displayed significant differences in performance parameters for routine immunization and COVID-19 vaccination (p<0.05), except in terms of coverage for IPV and COVID-19 vaccination.

Conclusion

The study highlights a reduction in routine immunization coverage during the pandemic, a concerning issue that increases the risk of vaccine-preventable diseases, particularly in rural areas.

The effect of mHealth on childhood vaccination in Africa: A systematic review and meta-analysis

INTRODUCTION

Vaccine-preventable diseases are the public health problems in Africa, although vaccination is an available, safe, simple, and effective method prevention. Technologies such as mHealth may provide maternal access to health information and support decisions on childhood vaccination. Many studies on the role of mHealth in vaccination decisions have been conducted in Africa, but the evidence needs to provide conclusive information to support mHealth introduction. This study provides essential information to assist planning and policy decisions regarding the use of mHealth for childhood vaccination.

METHODS

We conducted a systematic review and meta-analysis for studies applying mHealth in Africa for vaccination decisions following the Preferred Reporting Items for Systematic and Meta-Analysis [PRISMA] guideline. Databases such as CINAHL, EMBASE, PubMed, PsycINFO, Scopus, Web of Science, Google Scholar, Global Health, HINARI, and Cochrane Library were included. We screened studies in Endnote X20 and performed the analysis using Revman 5.4.1.

RESULTS

The database search yielded 1,365 articles [14 RCTs and 4 quasi-experiments] with 21,070 participants satisfied all eligibility criteria. The meta-analysis showed that mHealth has an OR of 2.15 [95% CI: 1.70-2.72; P<0.001; I2 = 90%] on vaccination rates. The subgroup analysis showed that regional differences cause heterogeneity. Funnel plots and Harbord tests showed the absence of publication bias, while the GRADE scale showed a moderate-quality body of evidence.

CONCLUSION

Although heterogeneous, this systematic review and meta-analysis showed that the application of mHealth could potentially improve childhood vaccination in Africa. It increased childhood vaccination by more than double [2.15 times] among children whose mothers are motivated by mHealth services. MHealth is more effective in less developed regions and when an additional incentive party with the messaging system. However, it can be provided at a comparably low cost based on the development level of regions and can be established as a routine service in Africa.

REGISTRATION

PROSPERO: CRD42023415956.

Vaccines for Children Provider Practices in the COVID-19 Vaccination Program: Barriers to Participation, Intentions to Offer COVID-19 Vaccination to Children Aged <5 Years, and Vaccination Promotion, United States, March 2022

The aim of the study was to assess barriers to Vaccines for Children (VFC) provider practices participating in the COVID-19 Vaccination Program and intentions to offer COVID-19 vaccination to children aged <5 years. We invited a random sample of 15 000 VFC provider practices in the United States to complete an online survey during February 28 to March 11, 2022. Of 2809 practices that completed the survey, 2246 (80.0%) were enrolled in the COVID-19 Vaccination Program. Concerns around staff resources, vaccine and supply storage space, and vaccine wastage from multidose vials were the most frequently reported program-enrollment barriers. Among enrolled practices that have decided whether to offer COVID-19 vaccination to the children aged <5 years, 1641 (88.8% of 1848) reported likely offering it to current patients, and 1165 reported likely offering it to children who are not current patients. Addressing participation barriers and encouraging active promotion may increase COVID-19 vaccination coverage of children.

Obscured inequity: How focusing on rates of disparities can conceal inequities in the reasons why adolescents are unvaccinated

Traditional sociodemographic disparities in adolescent vaccination initiation for the HPV, Tdap, and MenACWY vaccines have declined in the United States of America. This decline raises the question of whether inequities in access have been successfully addressed. This paper synthesizes research on the resource barriers that inhibit vaccination alongside research on vaccine hesitancy where parents actively refuse vaccination. To do so, I classify the primary reason why teens are unvaccinated in the National Immunization Survey-Teen 2012-2022 into three categories: resource failure, agentic refusal, and other reasons. I use three non-exclusive subsamples of teens who are unvaccinated against the HPV (N = 87,163), MenACWY (N = 54,726), and Tdap (N = 10,947) vaccines to examine the relative importance of resource failure reasons and agentic refusal reasons for non-vaccination across time and teens' sociodemographic characteristics. Results indicate that resource failure reasons continue to explain a substantial portion of the reasons why teens are unvaccinated and disproportionately affect racially/ethnically and economically marginalized teens. Thus, even as sociodemographic inequalities in rates of vaccination have declined, inequities in access remain consequential.

Pervasive Parental Hesitancy and Resistance towards Measles Rubella Vaccination in Jordan

Measles remains a highly contagious and potentially severe infectious disease, necessitating high vaccine coverage. However, misinformation and measles vaccine hesitancy/resistance have posed significant challenges to achieving this goal. The COVID-19 pandemic further exacerbated these challenges, leading to a measles outbreak in Jordan in 2023. This study aimed to investigate the acceptance of the measles rubella (MR) vaccine among parents in Jordan and to identify its associated determinants. This cross-sectional questionnaire-based study was conducted using a previously Arabic-validated version of the Parental Attitudes towards Childhood Vaccines (PACV) survey instrument. Data collection took place in October 2023, and the final study sample comprised a total of 391 parents, with mothers representing 69.8% of the participants (n = 273). The majority of participating parents expressed either resistance (n = 169, 43.2%) or hesitancy (n = 168, 43.0%) towards MR vaccination, while only 54 participants (13.8%) expressed MR vaccine acceptance. Multivariate analysis revealed that trust in vaccine safety/efficacy, behavior, and having fewer offspring were significantly associated with MR vaccine acceptance. The current study revealed a concerning level of MR vaccine hesitancy/resistance among parents in Jordan, which could signal a public health alarm in the country. Urgent and targeted interventions are strongly recommended to address this issue, including mass campaigns aimed at building trust in the MR vaccine's safety/efficacy. Additionally, there is an urgent need for effective public health initiatives to ensure sufficient measles vaccine coverage to prevent future outbreaks of this serious disease.

Mobile Vaccination Teams for Improving Vaccination Coverage in the Kyrgyz Republic: Results of a National Health System-Strengthening Project during the First Two Years of the COVID-19 Pandemic

(1) Background: This implementation study reports on the results of the mobile vaccination teams' (MVTs) activities during the first two years of the COVID-19 pandemic in Kyrgyzstan, when other vaccination services were disrupted. (2) Methods: Through a national health system-strengthening project under an order of the Ministry of Health, in 2020, the number of MVTs was increased, focusing on internal immigrant settlements around the cities of Bishkek and Osh and geographically remote areas. MVTs provided free vaccination services. (3) Results: MVTs vaccinated a total of 125,289 and 158,047 children in 2020 and 2021, respectively. The higher contribution of MVTs to vaccination coverage was in children under 5 years of age, with the three top vaccines being IPV (8.9%), MMR (7%), and PCV (6.6%). In 2021, 13,000 children who had not received an IPV vaccination and 8692 children who had not received the Pentavalent vaccine (DPT-HBV-Hib) were reached. The number of cases of vaccine-preventable disease reported in official statistics has reduced over time. (4) Conclusions: MVTs increased vaccination coverage in Kyrgyzstan, in particular in remote regions and migrant settlements, where it accounted for a considerable proportion of the vaccinated. This study adds to previous evidence in the literature of the role of MVTs as a strategy to improve immunization in hard-to-reach populations, particularly children.

Geographic proximity to immunization providers and vaccine series completion among children ages 0-24 months

OBJECTIVES

In the U.S., vaccination coverage is lower in rural versus urban areas. Spatial accessibility to immunization services has been a suspected risk factor for undervaccination in rural children. Our objective was to identify whether geographic factors, including driving distance to immunization providers, were associated with completion of recommended childhood vaccinations.

METHODS

We analyzed records from Montana's immunization information system for children born 2015-2017. Using geolocated address data, we calculated distance in road miles from children's residences to the nearest immunization provider. A multivariable log-linked binomial mixed model was used to identify factors associated with completion of the combined 7-vaccine series by age 24 months.

RESULTS

Among 26,085 children, 16,503 (63.3%) completed the combined 7-vaccine series by age 24 months. Distance to the nearest immunization provider ranged from 0 to 81.0 miles (median = 1.7; IQR = 3.2), with the majority (92.1%) of children living within 10 miles of a provider. Long distances (>10 miles) to providers had modest associations with not completing the combined 7-vaccine series (adjusted prevalence ratio [aPR]: 0.97, 95% confidence interval [CI]: 0.96-0.99). After adjustment for other factors, children living in rural areas (measured by rural-urban commuting area) were significantly less likely to have completed the combined 7-vaccine series than children in metropolitan areas (aPR: 0.88, 95% CI: 0.85-0.92).

CONCLUSIONS

Long travel distances do not appear to be a major barrier to childhood vaccination in Montana. Other challenges, including limited resources for clinic-based strategies to promote timely vaccination and parental vaccine hesitancy, may have greater influence on rural childhood vaccination.

A Structural Lens Approach to Vaccine Hesitancy and Identity

Vaccine hesitancy is an increasing global health threat, and to improve vaccine uptake, it is critical to account for identity-based considerations including racial and ethnic, religious, and contemporary socio-political identities. Using critical consciousness to create awareness of the diverse cultural viewpoints on vaccines can help providers have conversations that are identity aware, equity-focused, and linguistically sensitive with their patients. It is necessary to collaborate with patients, families, communities, and community leaders to share information about vaccines, their safety profiles, and on how to have vaccines readily accessible in each community, to protect children and adolescents against vaccine preventable illnesses.

Rural-Urban Disparities in Vaccine Hesitancy among Adults in South Tyrol, Italy

BACKGROUND

The demographic determinants of hesitancy in Coronavirus Disease-2019 (COVID-19) vaccination include rurality, particularly in low- and middle-income countries. In the second year of the pandemic, in South Tyrol, Italy, 15.6 percent of a representative adult sample reported hesitancy. Individual factors responsible for greater vaccination hesitancy in rural areas of central Europe are poorly understood.

METHODS

A cross-sectional survey on a probability-based sample of South Tyrol residents in March 2021 was analyzed. The questionnaire collected information on sociodemographic characteristics, comorbidities, COVID-19-related experiences, conspiracy thinking, and the likelihood of accepting the national vaccination plan. A logistic regression analysis was performed.

RESULTS

Among 1426 survey participants, 17.6% of the rural sample (n = 145/824) reported hesitancy with COVID-19 vaccination versus 12.8% (n = 77/602) in urban residents (p = 0.013). Rural residents were less likely to have post-secondary education, lived more frequently in households with children under six years of age, and their economic situation was worse than before the pandemic. Chronic diseases and deaths due to COVID-19 among close relatives were less frequently reported, and trust in pandemic management by national public health institutions was lower, as was trust in local authorities, civil protection, and local health services. Logistic regression models confirmed the most well-known predictors of hesitancy in both urban and rural populations; overall, residency was not an independent predictor.

CONCLUSION

Several predictors of COVID-19 vaccine hesitancy were more prevalent in rural areas than in urban areas, which may explain the lower vaccine uptake in rural areas. Rurality is not a determinant of vaccine hesitancy in the economically well-developed North of Italy.