Attitudinal and demographic predictors of measles, mumps and rubella (MMR) vaccine acceptance: development and validation of an evidence-based measurement instrument

Hesitant but vaccinated: Lessons learned from hesitant adopters

INTRODUCTION

The WHO SAGE vaccine hesitancy working group defined vaccine hesitancy as the delay or refusal of vaccination. Questions about individuals who become vaccinated while hesitant, or remain unvaccinated even though they are not hesitant, are unimaginable when starting from this behaviorally related definition of vaccine hesitancy. More critically, behaviorally related definitions limit the possibilities for vaccine hesitancy research to be translatable into clinical and public health practices that can increase vaccination.

LESSONS LEARNED

Emerging research on hesitant adopters provides several lessons for the conceptualization of vaccine hesitancy and how practitioners might increase vaccination. Conceptualizations of vaccine hesitancy must account for some of the big lessons we have learned from hesitant adopters: (1) vaccine hesitancy and vaccination co-occur for many; (2) vaccine hesitancy may not always be characterized by a punctuated point-in-time or moment; and (3) following from the second lesson, vaccine hesitancy may not be temporally bound to the moments preceding a vaccination decision.

CONCLUSIONS

We recommend conceptualizing vaccine-hesitant attitudes as distinctive from behaviors, and not temporally bound to moments preceding vaccination decisions. Sharpening the use of vaccine hesitancy and its temporal characteristics could benefit from engagement with the Life Course Paradigm. We recommend healthcare professionals provide a recommendation even when individuals express hesitancy. Finally, we recommend public health officials consider ways to improve the frequency and consistency of provider recommendations even among patients who are hesitant.

Attitudes towards vaccination among parents of children aged 0-5 years: A scale development study

BACKGROUND

Vaccination is the most important public health practice for preventing infectious diseases and maintaining health. However, some parents are hesitant to vaccinate their children.

DESIGN

This study was designed as an instrument development study.

METHODS

This study aimed to develop a scale to measure the attitudes of parents with children aged 0-5 years towards vaccination and to evaluate the validity and reliability of this scale. The data were collected from 691 participants between November 2020 and January 2021. During the development of the scale, experts provided feedback on its technical, content and language dimensions. The data were analysed using exploratory and confirmatory factor analyses for conceptual validity and Cronbach's α and item-level test-retest analyses for reliability.

RESULTS

The developed scale is a reliable and valid tool for measuring attitudes towards vaccination among parents (Cronbach's α = 0.97, variance explained by these 28-item two factors = 62.47%).

CONCLUSION

This scale can be used as a guide in measuring the attitudes of parents towards vaccination and determining the direction of primary health-care services based on the results of the measurement.

Overview of Tools and Measures Investigating Vaccine Hesitancy in a Ten Year Period: A Scoping Review

The challenge of vaccine hesitancy, a growing global concern in the last decade, has been aggravated by the COVID-19 pandemic. The need for monitoring vaccine sentiments and early detection of vaccine hesitancy in a population recommended by the WHO calls for the availability of contextually relevant tools and measures. This scoping review covers a ten year-period from 2010–2019 which included the first nine years of the decade of vaccines and aims to give a broad overview of tools and measures, and present a summary of their nature, similarities, and differences. We conducted the review using the framework for scoping reviews by Arksey and O’Malley (2005) and reported it following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews’ guidelines. Of the 26 studies included, only one was conducted in the WHO African Region. Measures for routine childhood vaccines were found to be the most preponderant in the reviewed literature. The need for validated, contextually relevant tools in the WHO Africa Region is essential, and made more so by the scourge of the ongoing pandemic in which vaccination is critical for curtailment.

Assessing the COVID-19 vaccine hesitancy in the Chinese adults using a generalized vaccine hesitancy survey instrument

The objectives of this study were to determine coronavirus disease 2019 (COVID-19) vaccination hesitancy and influencing factors in China, while broadening the applicability of the Vaccine Hesitancy Scale (VHS). A cross-sectional survey was conducted in China from 4th to 26th February 2021. Convenience sampling method was adopted to recruit participants. A total of 2,361 residents filled out the questionnaire. Confirmatory factor analysis was used on the validation set to confirm the latent structure that resulted from the exploratory factor analysis, which was conducted on the construction set. Multiple linear regression model analyses were used to identify significant associations between the identified the revised version of VHS subscales and hypothesized explanatory variables. Two subscales were identified within the VHS through data analysis, including "lack of confidence in the need for vaccines" and "aversion to the risk of side effects." The results indicated that the hesitancy of the participants in our sample was both driven the two mainly aspects. In addition, more than 40% of the participants expressed hesitation in half of the items in VHS. This study characterized COVID-19 vaccine hesitancy in China, and identified disparities in vaccine hesitancy by socio-demographic groups and knowledge about the vaccine. Knowledge of the vaccine was statistically linked to respondents' answers to the clustered 'lack of confidence' and 'risks perception' items. Our results characterize Chinese citizens' COVID-19 vaccine concerns and will inform targeted health communications.

MMR Vaccine Attitude and Uptake Research in the United Kingdom: A Critical Review

This review critically assesses the body of research about Measles-Mumps-and-Rubella (MMR) vaccine attitudes and uptake in the United Kingdom (UK) over the past 10 years. We searched PubMed and Scopus, with terms aimed at capturing relevant literature on attitudes about, and uptake of, the MMR vaccine. Two researchers screened for abstract eligibility and after de-duplication 934 studies were selected. After screening, 40 references were included for full-text review and thematic synthesis by three researchers. We were interested in the methodologies employed and grouped findings by whether studies concerned: (1) Uptake and Demographics; (2) Beliefs and Attitudes; (3) Healthcare Worker Focus; (4) Experimental and Psychometric Intervention; and (5) Mixed Methods. We identified group and individual level determinants for attitudes, operating directly and indirectly, which influence vaccine uptake. We found that access issues, often ignored within the public "anti-vax" debate, remain highly pertinent. Finally, a consistent theme was the effect of misinformation or lack of knowledge and trust in healthcare, often stemming from the Wakefield controversy. Future immunisation campaigns for children, including for COVID-19, should consider both access and attitudinal aspects of vaccination, and incorporate a range of methodologies to assess progress, taking into account socio-economic variables and the needs of disadvantaged groups.

Resources for assessing parents' vaccine hesitancy: a systematic review of the literature

The concept of Vaccine Hesitancy has begun to appear in the scientific landscape, referring to the reluctance of a growing proportion of people to accept the vaccination offer. A variety of factors were identified as being associated with vaccine hesitancy but there was no universal algorithm and currently there aren’t any established metrics to assess either the presence or impact of vaccine hesitancy. The aim of this study was to systematically review the published questionnaires evaluating parental vaccine hesitancy, to highlight the differences among these surveys and offer a general overview on this matter. This study offers a deeper perspective on the available questionnaires, helping future researches to identify the most suitable one according to their own aim and study setting.

The impact of parents' health behaviours on their preferences regarding vaccinations in Bialystok, Poland

BACKGROUND

Currently, as the number of vaccinated children in Poland and throughout Europe is decreasing. Many factors impact on the rate vaccination and parents' health behaviours may affect the frequency of vaccinations. The aim of the study was to assess the association of parents' health behaviors with children's vaccinations.

METHODS

A cross-sectional survey was conducted from July 2015 to June 2016 to assess to assess the association of parents' health behaviors with children's vaccinations in Białystok city, Poland. We used the the Inventory of Health Behaviours and an original questionnaire including demographic data and questions about vaccination. Three hundred parents were recruited from the Pro Medica Family Medica Center in Bialystok, Poland.

RESULTS

Only 3.7% of respondents did not vaccinate their children. The level of health behaviours was average in 42.3% of the respondents, low in 33%, and high in 24.7%. Significant differences in health behaviours, mainly the level of normal eating habits (p = 0.038) and positive mental attitude (p = 0.022), were found in relation to views on the toxicity of vaccines. Participants who reported that vaccines can cause autism engaged in a higher level of prophylactic behaviours. Respondents who vaccinated their children with combined vaccines had a significantly higher level of health practices.

CONCLUSIONS

Parents preferred health behaviours did not effect on children vaccination. Parents who believed in the toxicity of vaccines were more concerned about proper nutrition, had a positive mental attitude, and engaged in a higher level of preventive behaviours and health practices. Parents who did not vaccinate their children had lower levels of normal eating habits. Parents who vaccinated their children with combined vaccines had a higher level of health behaviours, especially in terms of health practices.

Factors associated with parental acceptance of influenza vaccination for their children: the evidence from four cities of China

BACKGROUND

It is necessary and urgent to vaccinate 245 million Chinese children against influenza pandemics. The main purpose of this study was to evaluate different psychological and demographic factors that influence parental willingness to vaccinate their children against influenza.

METHODS

A hybrid theoretical framework was expanded and verified with 462 sample data collected from four cities in China. Structural equation models were used to test nine theoretical hypotheses, and the non-standardized coefficient method was used to discuss the moderating effects among demographic variables.

RESULTS

Knowledge is considered to be the significant factor of performance expectancy (β = 0.228), effort expectancy (β = 0.227) and perceived risk (β = -0.138), and social influence also has the significant impacts on the above three variables, with β values of 0.437, 0.386, and -0.172. Performance expectancy (β = 0.402), effort expectancy (β = 0.343), and perceived risk (β = -0.244) thus significantly affect parental behavioral intention regarding children's influenza vaccination. Gender, education, and kids' gender are demographic variables with significant moderating effects, while age, income, number of kids are not significant.

CONCLUSION

To improve the acceptability of influenza vaccination among Chinese children, the promoting policies should emphasize on public knowledge and social influence, as well as effectiveness, affordability, and safety of vaccination.

To Vaccinate or Not: The Relative Impact of Attitudes toward Autism Spectrum Disorders and the Ability to Interpret Scientific Information on Vaccination Decisions

Background. This pilot study investigated vaccine decision making, i.e., the relationships between knowledge and attitudes towards autism spectrum disorders (ASD), scientific literacy, attitudes toward the (MMR) vaccine, and children’s MMR vaccination status. Methods. A sample of 132 parents and expectant parents (mean age 38.40 years; >60% with university education) participated in a survey where they were asked about their knowledge of ASD, attitudes towards ASD and MMR, and their children’s MMR vaccine status. The participants also completed a standardized science test (The American College Test) to test their scientific literacy. Results. Knowledge of ASD was positively correlated with attitudes towards ASD. Attitudes towards ASD were positively correlated with scientific literacy and attitudes towards MMR. Attitudes towards MMR were positively correlated with MMR vaccine status (i.e., vaccination decision). Discussion. Factors other than scientific literacy seem to contribute towards children’s MMR vaccine status such as attitudes towards MMR. However, these are preliminary findings and need to be interpreted with caution.

Using protection motivation theory to predict intention to adhere to official MMR vaccination recommendations in Switzerland

Switzerland has not yet reached the measles vaccination coverage of 95 percent that is recommended by the World Health Organization to achieve herd immunity. Within the overall objective of informing effective ways to promote the combined Measles, Mumps, Rubella (MMR) vaccination in Switzerland, the aim of this study was to identify predictors of parents' intention to adhere to official MMR vaccination recommendations. Between October 2012 and January 2013, we surveyed 554 parents of middle school students aged 13 to 15 in Ticino, Switzerland. Guided by Protection Motivation Theory (PMT), the survey covered predictors related to threat and coping appraisal with regards to measles and the MMR vaccine, MMR-related social attitudes and social norms, past experience with the disease and the vaccine, and information sources in the MMR vaccine context. Data were analyzed using Structural Equation Modelling. Among central PMT concepts describing people's threat and coping appraisal, only response (vaccination) efficacy showed to be directly related to parents' intention to adhere to MMR vaccination recommendations (B = .39, p < .001). In addition, social attitudes (B = .38, p < .001) were a direct predictor. Furthermore, social attitudes, social norms, knowing somebody who experienced MMR vaccination side effects, and having sought MMR information from public health institutions, all indirectly predicted parents' intention to adhere to MMR recommendations by activating different threat and coping appraisal mechanisms. To conclude, future communication measures from public health institutions should highlight the altruistic aspect (herd immunity) of the immunization practice as well as present evidence on the high effectiveness of the vaccination in reducing the risk at both the individual and collective levels of getting infected with measles.

Assessing vaccine hesitancy in the UK population using a generalized vaccine hesitancy survey instrument

BACKGROUND

In many regions of the world, vaccine hesitancy has become an important concern to public health. A key part of any effective solution to it is to gain an in-depth understanding of the problem: its scope, who holds hesitant views and for which reasons.

METHODS

We adapt the original 10-item Vaccine Hesitancy Scale (VHS), which targets parental attitudes, to a more generic version that captures general attitudes to vaccination. We use this adapted VHS in a sample of 1402 British citizens, selected from a large online panel (N > 1,000,000) based on quota for age, gender, educational attainment and region (response rate 43%). The existence of VHS subscales is evaluated via exploratory and confirmatory factor analysis. We describe the extent of vaccine hesitancy in the sample, and use simple and multiple regression analysis to examine associations between respondent characteristics and vaccine hesitancy.

RESULTS

Despite ambiguities in defining hesitancy, we found that a substantial part of our sample held hesitant views about vaccination, particularly for those items reflecting aversion to risks of side effects. Four percent responded in a hesitant way to all ten items and ninety to at least one of the ten items. In line with recent studies in other populations, we identified two subscales within the VHS: lack of confidence in the need for vaccines and aversion to the risk of side effects. We found significant associations between hesitancy and various respondent characteristics but the predictive power of these associations remained limited.

CONCLUSION

Our study suggests that whereas a substantial percentage of the British population is vaccine hesitant, these views are not clustered in typical demographic features. The small but important adaptation of the VHS to target general attitudes seems to result in highly similar psychometric characteristics as the original scale that exclusively targets parents. We provide suggestions for further validation of the VHS.

Parental perceptions of human papillomavirus vaccination in central China: the moderating role of socioeconomic factors

Background: The huge gap in adolescent human papillomavirus (HPV) uptake between China (< 2%) and developed countries (> 60%) indicates the necessity of comprehensive examination on the modifiable factors for parents' decision-making. The present study investigated parental perceptions of HPV vaccination for children in China from a socio-economic perspective. Methods: Parents of 9-to-14-year-old adolescents who understood the HPV vaccination (n = 925) completed our questionnaire survey in Fall 2017. Based on the structural equation modeling, we examined the relationship among knowledge, awareness, and intentions of 20 items by 7-point Likert scale, the moderating effects also were tested among 5 socioeconomic variables. Results: Parents of female students have more positive intention about the HPV vaccination than male students' parents (3.74 vs 2.80, p < 0.001). Parents of 12-14-years old students have higher average scores in knowledge (p = 0.006) and intention (p < 0.001) than that of 9-11-years old students' parents. The average score of mothers on knowledge (p = 0.018) and awareness (p < 0.001) was lower than that of fathers. The elder parents (≥ 50 years) performed significantly better on knowledge (p < 0.001) and awareness (p < 0.001) than the other two subgroups. Annual household income is an important factor in determining the knowledge (p = 0.0017), awareness (p < 0.001), and intention (p < 0.001). Knowledge and awareness were considered as the positive determinant of intention, and awareness was partial mediator. Child gender (P = 0.046), child age (P = 0.004), parent gender (P = 0.043) and parental age (P = 0.021) were significant moderators. Conclusion: To improve the acceptability of HPV vaccination among Chinese adolescents, policymakers should develop positive strategies for their parents.

Perspectives on the Measles, Mumps and Rubella Vaccination among Somali Mothers in Stockholm

Background: Vaccination hesitancy and skepticism among parents hinders progress in achieving full vaccination coverage. Swedish measles, mumps and rubella (MMR) vaccine coverage is high however some areas with low vaccination coverage risk outbreaks. This study aimed to explore factors influencing the decision of Somali parents living in the Rinkeby and Tensta districts of Stockholm, Sweden, on whether or not to vaccinate their children with the measles, mumps and rubella (MMR) vaccine. Method: Participants were 13 mothers of at least one child aged 18 months to 5 years, who were recruited using snowball sampling. In-depth interviews were conducted in Somali and Swedish languages and the data generated was analysed using qualitative content analysis. Both written and verbal informed consent were obtained from participants. Results: Seven of the mothers had not vaccinated their youngest child at the time of the study and decided to postpone the vaccination until their child became older (delayers). The other six mothers had vaccinated their child for MMR at the appointed time (timely vaccinators). The analysis of the data revealed two main themes: (1) barriers to vaccinate on time, included issues surrounding fear of the child not speaking and unpleasant encounters with nurses and (2) facilitating factors to vaccinate on time, included heeding vaccinating parents’ advice, trust in nurses and trust in God. The mothers who had vaccinated their children had a positive impact in influencing other mothers to also vaccinate. Conclusions: Fear, based on the perceived risk that vaccination will lead to autism, among Somali mothers in Tensta and Rinkeby is evident and influenced by the opinions of friends and relatives. Child Healthcare Center nurses are important in the decision-making process regarding acceptance of MMR vaccination. There is a need to address mothers’ concerns regarding vaccine safety while improving the approach of nurses as they address these concerns.

Predicting behavioral intentions to children vaccination among Chinese parents: an extended TPB model

Parental behavioral intentions play a key role in children vaccination. The present study looks at how parental expectations for the vaccination influence their attitudes and behavioral intentions toward children's immunization. The theoretical model is developed on TPB model and empirically tested with sample data from 380 children aged 0-7 years in mainland China. The structural equation modeling and multi-group analysis were used in the model to demonstrate the impact of the vaccination services quality, vaccination promotions and public opinions on attitudes and vaccination behavioral intention. Results support the study's hypotheses and indicate that Vaccination Services Quality (VSQ), Vaccination Promotions (VAP) and Public Opinions (PUO) have positive effects on Attitudes (ATT) and Vaccination Behavioral Intention (VAI), VSQ has the strongest standardized path (.594) while PUO has the least influence (.131), and Attitude is complete mediation in all paths. Attitude is key factor that determine the parental behavioral intentions, and the internal perception comes from the vaccination services quality and the external influence comes from the social environment affect the parental attitude. Governments should implement effective policies and improve vaccination services quantity to eliminate parental misunderstandings.

Vaccination hesitancy in the antenatal period: a cross-sectional survey

BACKGROUND

Recent reports of childhood vaccination coverage in Australia have shown steadily improving vaccination coverage and narrowing differences between highest and lowest coverage regions, yet the NSW North Coast consistently has the lowest coverage rates nationally. Better understanding of parents' vaccination attitudes and actions within this region may guide strategies to improve uptake. The antenatal period is when many parents explore and consolidate vaccination attitudes and so is pivotal for study.

METHODS

Women attending public antenatal clinics at six NSW North Coast hospitals completed a 10-min cross-sectional survey capturing stage of decision-making and decisional-conflict as well as vaccination hesitancy, attitudes, intentions and actions. Unscored responses were analysed for individual items. Decisional conflict subscales were scored using published algorithms. For consented children, immunisation status was assessed at 8 months using the Australian Immunisation Register. For Likert scale items, odds ratios and Fisher's exact, chi-squared and Chasson's tests assessed differences between subgroups. Wilcoxon rank-sum tests assessed differences between subgroups for items on scales of 0-to-10 and decisional conflict sub-scale scores.

RESULTS

First-time mothers were 3 times more likely than others (OR = 3.40, 95% CI 1.34-8.60) to identify as unsure, somewhat or very hesitant. Most respondents (92.2%) wanted their new baby to receive all recommended vaccinations. Many had high or moderate levels of concern about vaccine side effects (25.4%), safety (23.6%) and effectiveness (23.1%). Increased hesitancy was associated with decreased confidence in the schedule (p < 0.001), decreased trust in child's doctor (p < 0.0001), decreased perceived protection from disease (p < 0.05) and increased decisional conflict on all measured subscales (p < 0.0001). First-time mothers had higher decisional conflict on values clarity, support and uncertainty sub-scales. By 8 months of age, 83.2% of infants were fully vaccinated. Those with none or a few minor concerns were over 8 times more likely than others to vaccinate on schedule (OR = 8.7, 1.3-56.7).

CONCLUSIONS

Importantly this study provides further strong justification to talk with women about vaccination during pregnancy and particularly to ensure that first-time mothers are offered assistance in making these important decisions, where indicated. Further research should focus on optimising the timing, content and delivery style of perinatal interventions.

The vaccine hesitancy scale: Psychometric properties and validation

INTRODUCTION

The SAGE Working Group on Vaccine Hesitancy developed a vaccine hesitancy measure, the Vaccine Hesitancy Scale (VHS). This scale has the potential to aid in the advancement of research and immunization policy but has not yet been psychometrically evaluated.

METHODS

Using a cross-sectional design, we collected self-reported survey data from a large national sample of Canadian parents from August to September 2016. An online questionnaire was completed in English or French. We used exploratory and confirmatory factor analysis to identify latent constructs underlying parents' responses to 10 VHS items (response scale 1-5, with higher scores indicating greater hesitancy). In addition to the VHS, measures included socio-demographics items, vaccine attitudes, parents' human papillomavirus (HPV) vaccine decision-making stage, and vaccine refusal.

RESULTS

A total of 3779 Canadian parents completed the survey in English (74.1%) or French (25.9%). Exploratory and confirmatory factor analysis revealed a two-factor structure best explained the data, consisting of 'lack of confidence' (M = 1.98, SD = 0.72) and 'risks' (M = 3.07, SD = 0.95). Significant Pearson correlations were found between the scales and related vaccine attitudes. ANOVA analyses found significant differences in the VHS sub-scales by parents' vaccine decision-making stages (p < .001). Independent samples t-tests found that the VHS sub-scales were associated with HPV vaccine refusal and refusing another vaccine (p < .001). Socio-demographic differences in the VHS were found; however, effect sizes were small (η² < 0.02).

CONCLUSIONS

The VHS was found to have two factors that have construct and criterion validity in identifying vaccine hesitant parents. A limitation of the VHS was few items that loaded on the 'risks' component and a lack of positively and negatively worded items for both components. Based on these results, we suggest modifying the wording of some items and adding items on risk perceptions.

Measles vaccination status of nurses and associated factors during community measles outbreaks

AIM

To identify the measles vaccination status of nurses, their knowledge and health beliefs about measles, and the associated factors that influence their measles vaccination status during a community measles outbreak in South Korea.

METHODS

The participants were 156 nurses from four hospitals in a region where a community measles outbreak occurred.

RESULTS

The measles vaccination rate of the nurses was 73.7%. The nurses' health belief score about measles was 2.44 out of 4 and their knowledge score was 73.85 out of 100. The associated factors that influenced the nurses' measles vaccination status included their experience of caring for patients with measles and a low level of perceived barriers to vaccination.

CONCLUSION

In order to encourage an increased measles vaccination rate in nurses, hospitals should screen susceptible nurses and offer vaccination. Effective measles vaccination campaigns and educational programs are also required in hospitals.

Validation of a scale to measure parental psychological empowerment in the vaccination decision

Background and aims.

Parents’ empowerment is advocated to promote and preserve an informed and autonomous decision regarding their children’ immunization. The scope of this study is to develop and evaluate the psychometric properties of an instrument to measure parents’ psychological empowerment in their children’s vaccination decision and propose a context-specific definition of this construct.

Materials and methods.

Grounding in previous qualitative data, we generated an initial pool of items which was later content and face validated by a panel of experts. A pretest allowed us to reduce the initial pool to 9 items. Convergent and discriminant validity measures included the General Self-Efficacy Scale, a Psychological Empowerment Scale, and the Control Preference Scale. Vaccination-related outcomes such as attitude and intention were also included.

Results.

Principal Component Analysis revealed a 2-factor structure, with each factor composed of 2 items. The first factor concerns the perceived influence of one’s personal and family experience with vaccination, while the second factor represents the desire not to ask other parents about their experience with vaccination and their lack of interest in other parents’ vaccination opinion.

Conclusions

In light of its association with positive immunization-related outcomes, public health efforts should be directed to reinforce parents’ empowerment.

Socioeconomic differences in childhood vaccination in developed countries: a systematic review of quantitative studies

INTRODUCTION

The reasons for vaccine hesitancy and its relation to individual socioeconomic status (SES) must be better understood. Areas covered: This review focused on developed countries with programs addressing major financial barriers to vaccination access. We systematically reviewed differences by SES in uptake of publicly funded childhood vaccines and in cognitive determinants (beliefs, attitudes) of parental decisions about vaccinating their children. Using the PRISMA statement to guide this review, we searched three electronic databases from January 2000 through April 2016. We retained 43 articles; 34 analyzed SES differences in childhood vaccine uptake, 7 examined differences in its cognitive determinants, and 2 both outcomes. Expert commentary: Results suggest that barriers to vaccination access persist among low-SES children in several settings. Vaccination programs could be improved to provide all mandatory and recommended vaccines 100% free of charge, in both public organizations and private practices, and to reimburse vaccine administration. Multicomponent interventions adapted to the context could also be effective in reducing these inequalities. For specific vaccines (notably for measles, mumps, and rubella), in UK and Germany, uptake was lowest among the most affluent. Interventions carefully tailored to respond to specific concerns of vaccine-hesitant parents, without reinforcing hesitancy, are needed.

Knowledge, attitudes and opinions towards measles and the MMR vaccine across two NSW cohorts

OBJECTIVE

Although the number of national measles cases has greatly decreased since 1980s, there has been resurgence in disease incidence in recent years. While parental knowledge and attitudes toward both disease and vaccinations are known to influence vaccine uptake, the contribution of these factors toward vaccination rates in NSW populations has not been studied. The aim of this study was to investigate the knowledge and opinions on measles and MMR vaccine in NSW Central and North Coast regions.

METHODS

Parents (n=201) of children <12 years were surveyed with a purpose design survey at public beaches at the Central Coast and community markets at the North Coast.

RESULTS

Eight per cent of respondents reported not immunising their child with MMR vaccine. Most respondents recognised that measles is a highly contagious disease. Non-immunisers were found to be older, had a lower perceived severity of measles, were less likely to agree with the efficacy and safety of the vaccine, and were more likely to have encountered someone who had suffered side-effects of the vaccine.

CONCLUSIONS

There is considerable concern over safety of MMR vaccine among non-immunisers. Implications for public health: Improving confidence in MMR vaccine should be a target of future public health interventions.

Sociodemographic predictors of variation in coverage of the national shingles vaccination programme in England, 2014/15

INTRODUCTION

In September 2013, England introduced a shingles vaccination programme to reduce incidence and severity of shingles in the elderly. This study aims to assess variation in vaccine coverage with regards to selected sociodemographic factors to inform activities for improving equity of the programme.

METHODS

Eligible 70year-olds were identified from a national vaccine coverage dataset in 2014/15 that includes 95% of GPs in England. NHS England Local Team (LT) and index of multiple deprivation (IMD) scores were assigned to patients based on GP-postcode. Vaccine coverage (%) with 95% confidence intervals (CIs), were calculated overall and by LT, ethnicity and IMD, using binomial regression.

RESULTS

Of 502,058 eligible adults, 178,808 (35.6%) had ethnicity recorded. Crude vaccine coverage was 59.5% (95%CI: 59.3-59.7). Coverage was lowest in London (49.6% coverage, 95%CI: 49.0-50.2), and compared to this coverage was significantly higher in all other LTs (+6.3 to +10.4, p<0.001) after adjusting for ethnicity and IMD. Coverage decreased with increasing deprivation and was 8.2% lower in the most deprived (95%CI: 7.3-9.1) compared with the least deprived IMD quintile (64.1% coverage, 95%CI: 63.6-64.6), after adjustment for ethnicity and LT. Compared with White-British (60.7% coverage, 95%CI: 60.5-61.0), other ethnic groups had between 4.0% (Indian) and 21.8% (Mixed: White and Black African) lower coverage. After adjusting for IMD and LT, significantly lower coverage by ethnicity persisted in all groups, except in Mixed: Other, Indian and Bangladeshi compared with White-British.

CONCLUSIONS

After taking geography and deprivation into account, shingles vaccine coverage varied by ethnicity. White-British, Indian and Bangladeshi groups had highest coverage; Mixed: White and Black African, and Black-other ethnicities had the lowest. Patients' ethnicity and IMD are predictors of coverage which contribute to, but do not wholly account for, geographical variation coverage. Interventions to address service-related, sociodemographic and ethnic inequalities in shingles vaccine coverage are required.

Information sources and knowledge on vaccination in a population from southern Italy: The ESCULAPIO project

Vaccine knowledge of the general population is shaped by different information sources and strongly influences vaccination attitudes and uptake. The CCM-Italian Ministry of Health ESCULAPIO project attempted to identify the role of such information sources, in order to address adequate strategies to improve information on vaccines and vaccine preventable diseases. In the present study, data on 632 adults from Southern Italy regarding information sources were collected, and their perceived and actual knowledge on vaccinations were compared and analyzed in relation to socio-demographic characteristics and information sources. The main reported reference sources were general practitioners (GPs) (42.5%) and pediatricians (33.1%), followed by mass media (24.1%) and the Internet (17.6%). A total of 45.4% reported they believed to be informed (45.4%), while those estimated to be truly informed were 43.8%. However, as showed in the multivariate logistic regression, people having the perception to be correctly informed ascribed their good knowledge to their profession in the health sector (Adj OR 2.28, CI 1.09-4.77, p < 0.05) and to friends/relatives/colleagues (AdjOR 6.25, CI 2.38-16.44, p < 0.001), while the non-informed population thought the responsibility had to be attributed to mass media (AdjOR 0.45, CI 0.22-0.92, p < 0.05). Those showing the real correct information, instead, were younger (AdjOR 1.64, CI 1.04-2.59, p < 0.05), and their main reference sources were pediatricians (AdjOR 1.63, CI 1.11-2.39, p < 0.05) and scientific magazines (Adj OR 3.39, CI 1.51-7.59, p < 0.01). Only 6% knew the "VaccinarSì" portal, developed to counter the widespred antivaccine websites in Italy. The post-survey significant increase of connections to "VaccinarSi" could be ascribed to the counselling performed during questionnaire administration. Strategies to improve information about vaccination should be addressed to fortifying healthcare workers knowledge in order to make them public health opinion leaders. General population should be provided with correct indications on trustworthy websites on vaccines to contrast false information supplied by anti-vaccinists on their own websites or social networks pages and on the mass media.

Intentions to receive a potentially available Lyme disease vaccine in an urban sample

OBJECTIVES

The only human Lyme disease vaccine of LYMErix was voluntarily removed from the market in the United States in 2002 for a number of reasons. A new human Lyme disease vaccine is currently being developed. We would like any future approved human Lyme disease vaccine to be of interest and marketable to consumers.

METHODS

We surveyed 714 participants to determine variables associated with intentions to receive a Lyme disease vaccine. Predictor variables included demographics, protection motivational theory, Lyme disease knowledge, Lyme disease preventive behaviors, beliefs and perceived health.

RESULTS

We found in multivariate linear regression analyses that Asian/Asian American race/ethnicity (p < 0.001), South Asian race/ethnicity (p = 0.01) and coping appraisal variables of response efficacy (p < 0.001) and self-efficacy (p < 0.001) were each significantly associated with increased intentions. The belief that vaccines are typically not safe was significantly associated with decreased intentions (p = 0.03).

CONCLUSIONS

Asian/Asian American and South Asian race/ethnicities have a strong interest in receiving a Lyme disease vaccine. Although pharmaceutical companies may benefit by advertising a Lyme disease vaccine to Asian/Asian Americans and South Asians, marketers need to address and use approaches to interest those from other race/ethnicities. Also, marketers need to address the erroneous belief that vaccines are typically not safe in order to interest those with such beliefs to use a Lyme disease vaccine.

Determinants of European parents' decision on the vaccination of their children against measles, mumps and rubella: A systematic review and meta-analysis

Low measles, mumps and rubella (MMR) immunization levels in European children highlight the importance of identifying determinants of parental vaccine uptake to implement policies for increasing vaccine compliance. The aim of this paper is to identify the main factors associated with partial and full MMR vaccination uptake in European parents, and combine the different studies to obtain overall quantitative measures. This activity is included within the ESCULAPIO project, funded by the Italian Ministry of Health. ORs and CIs were extracted, sources of heterogeneity explored and publication bias assessed. Forty-five papers were retrieved for the qualitative study, 26 of which were included in the meta-analysis. The following factors were associated with lower MMR vaccine uptake: misleading knowledge, beliefs and perceptions on vaccines (OR 0.57, CI 0.37-0.87); negative attitudes and behaviors toward vaccination (OR 0.71, CI 0.52-0.98); demographic characteristics, such as different ethnicity in Southern populations (OR 0.44, CI 0.31-0.61), higher child's age (OR 0.80, CI 0.76-0.85); low socio-economic status (OR 0.64, CI 0.51-0.80), especially low income (OR 0.39, CI 0.25-0.60) and education (OR 0.64, CI 0.48-0.84), high number of children (OR 0.54, CI 0.42-0.69), irregular marital status (OR 0.80, CI 0.66-0.96). The factors explaining heterogeneity were country location, administration modality, collection setting and responses reported on MMR alone or in combination. Findings from this study suggest policy makers to focus communication strategies on providing better knowledge, correct beliefs and perceptions on vaccines, and improving attitudes and behaviors in parents; and to target policies to people of ethnic minority from Southern Europe, low educated and deprived, with higher number of children and non-married marital status.

What are parents' perspectives on psychological empowerment in the MMR vaccination decision? A focus group study

OBJECTIVES

Most developed countries do not have compulsory immunisation requirements, but instead issue recommendations. Although parents are expected to make an informed, autonomous (ie, empowered) decision regarding their children's vaccinations, there is no evidence about how parents' interpret this demand nor on the latitude of their decision-making. The goal of this study is to gain insights from parents residing in a low measles-mumps-rubella (MMR) uptake area on what constitutes feelings of empowerment in the decision they have to make on their child's MMR vaccination.

DESIGN

A qualitative study employing focus group interviews.

SETTING

11 vaccination centres and hospitals in the Province of Trento, Italy.

PARTICIPANTS

24 mothers and 4 fathers of children for whom the MMR vaccination decision was still pending participated in 6 focus groups.

RESULTS

Autonomy and competence were salient themes in relation to empowerment, and were further connected with beliefs regarding legal responsibility and ethics of freedom concerning the decision, parents' relationship with the paediatrician (trust), feelings of relevance of the decision and related stress, and seeking, avoidance, or fear of vaccination-related information. Competence was interpreted as medical knowledge and information-seeking skills, but it was also related to the extent parents perceived the paediatrician to be competent.

CONCLUSIONS

Since parents' interpretation of empowerment goes beyond mere perceptions of being informed and autonomous and differs across individuals, it is important that this construct be correctly interpreted and implemented by best practice, for instance by explicitly adopting a relational conception of autonomy. Knowing whether parents want to make an empowered decision and what their information and autonomy needs are might help health professionals adapt their communication about immunisation, and promote parental perception of making an informed, autonomous decision.

Factors Influencing University Nursing Students' Measles Vaccination Rate During a Community Measles Outbreak

PURPOSE

The purpose of this study was to survey the current state of measles vaccination in university nursing students during a measles outbreak and to identify factors influencing nursing students' vaccination rate.

METHODS

In 2014, this study used a self-administered questionnaire to survey 380 university nursing students. Factors influencing measles vaccination were identified through logistic regression analysis using variables between the vaccinated and nonvaccinated groups.

RESULTS

Measles vaccination rate was 52.1%. The vaccination rate was significantly higher in juniors, seniors, and those who had heard about measles. In relation to health beliefs, the measles vaccination rate was higher when perceived benefits were high and perceived barriers were low.

CONCLUSIONS

A systematic measles vaccination program targeting nursing students upon their entry to university is needed. In order to increase the measles vaccination rate, application of effective promotion campaigns and education programs is necessary.

The 5As: A practical taxonomy for the determinants of vaccine uptake

Suboptimal vaccine uptake in both childhood and adult immunisation programs limits their full potential impact on global health. A recent progress review of the Global Vaccine Action Plan stated that "countries should urgently identify barriers and bottlenecks and implement targeted approaches to increase and sustain coverage". However, vaccination coverage may be determined by a complex mix of demographic, structural, social and behavioral factors. To develop a practical taxonomy to organise the myriad possible root causes of a gap in vaccination coverage rates, we performed a narrative review of the literature and tested whether all non-socio-demographic determinants of coverage could be organised into 4 dimensions: Access, Affordability, Awareness and Acceptance. Forty-three studies were reviewed, from which we identified 23 primary determinants of vaccination uptake. We identified a fifth domain, Activation, which captured interventions such as SMS reminders which effectively nudge people towards getting vaccinated. The 5As taxonomy captured all identified determinants of vaccine uptake. This intuitive taxonomy has already facilitated mutual understanding of the primary determinants of suboptimal coverage within inter-sectorial working groups, a first step towards them developing targeted and effective solutions.

Addressing issues of vaccination literacy and psychological empowerment in the measles-mumps-rubella (MMR) vaccination decision-making: a qualitative study

Background

Whether or not to vaccinate one’s child is one of the first health-related decisions parents have to make after their child’s birth. For the past 20 years, the share of parents choosing not to immunize their children has increased in many countries, for various reasons. Among these, rumors affirming that vaccinations contain dangerous chemicals or might trigger severe chronic diseases have negatively affected parental attitudes towards pediatric immunizations, particularly the vaccination against measles, mumps and rubella (MMR), raising a number of public health concerns. The primary aim of this qualitative study is to understand what drives parents’ decision, giving special attention to vaccination literacy and psychological empowerment in such a context.

Methods

Twenty individual semi-structured interviews were conducted in the Canton of Ticino (Switzerland) between January and June 2014. Participants were either mothers or fathers of children less than 1 year old living in Switzerland. An inductive thematic analysis was performed to identify the main themes with regard to vaccination literacy and psychological empowerment in the MMR vaccination decision-making.

Results

Parents’ reports yielded four main themes: (a) the paradox of the free choice, referring to the misinterpretation of current vaccination policies; (b) giving up the power, pointing at the outcomes of a low perceived competence; (c) a far-reaching decision, reflecting the importance attributed to the MMR choice and the different levels of impact the decision can have; (d) the demand for shared-decision making, referring to the parental needs in relation to the child’s healthcare provider.

Conclusion

Understanding what drives parents’ management of their children’s immunization schedule in terms of vaccination literacy and psychological empowerment can help health professionals to communicate more effectively with parents in order to facilitate an informed decision, and stakeholders to design tailored health education programs and materials. This can ultimately help increase the coverage of the MMR vaccination.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2200-9) contains supplementary material, which is available to authorized users.

A Multidisciplinary Research Agenda for Understanding Vaccine-Related Decisions

There is increasingly broad global recognition of the need to better understand determinants of vaccine acceptance. Fifteen social science, communication, health, and medical professionals (the “Motors of Trust in Vaccination” (MOTIV) think tank) explored factors relating to vaccination decision-making as a step to building a multidisciplinary research agenda. One hundred and forty seven factors impacting decisions made by consumers, professionals, and policy makers on vaccine acceptance, delay, or refusal were identified and grouped into three major categories: cognition and decision-making; groups and social norms; and communication and engagement. These factors should help frame a multidisciplinary research agenda to build an evidence base on the determinants of vaccine acceptance to inform the development of interventions and vaccination policies.

Toward interactive, Internet-based decision aid for vaccination decisions: better information alone is not enough

Vaccination decisions, as in choosing whether or not to immunize one's small child against specific diseases, are both psychologically and computationally complex. The psychological complexities have been extensively studied, often in the context of shaping convincing or persuasive messages that will encourage parents to vaccinate their children. The computational complexity of the decision has been less noted. However, even if the parent has access to neutral, accurate, credible information on vaccination risks and benefits, he or she can easily be overwhelmed by the task of combining this information into a well-reasoned decision. We argue here that the Internet, in addition to its potential as an information source, could provide useful assistance to parents in integrating factual information with their own values and preferences - that is, in providing real decision aid as well as information aid. We sketch one approach for accomplishing this by means of a hierarchy of interactive decision aids ranging from simple advice to full-scale decision analysis.

U.K. parents' decision-making about measles-mumps-rubella (MMR) vaccine 10 years after the MMR-autism controversy: a qualitative analysis

BACKGROUND AND OBJECTIVES

Public concern about an unsubstantiated link between MMR vaccine and autism stemmed from a 1998 paper by Dr Andrew Wakefield and colleagues, and the substantial media coverage which that work attracted. Though the Wakefield paper is now discredited and an MMR-autism link has never been demonstrated empirically, this concern has manifested in over a decade of suboptimal MMR uptake. Few qualitative studies have explored parents' MMR decision-making since uptake began to improve in 2004. This study updates and adds methodological rigour to the evidence base.

METHODS

24 mothers planning to accept, postpone or decline the first MMR dose (MMR1) for their 11-36 month-old children, described their decision-making in semi-structured interviews. Mothers were recruited via General Practice, parents' groups/online forums, and chain referral. MMR1 status was obtained from General Practice records 6 months post-interview. Interview transcripts were coded and interpreted using a modified Grounded Theory approach.

RESULTS

Five themes were identified: MMR vaccine and controversy; Social and personal consequences of MMR decision; Health professionals and policy; Severity and prevalence of measles, mumps and rubella infections; Information about MMR and alternatives. Results indicated that MMR1 acceptors were sympathetic toward Wakefield as a person, but universally rejected his study which sparked the controversy; parents opting for single vaccines expressed the sense that immune overload is not a consideration but that not all three components of MMR are warranted by disease severity; and MMR1 rejectors openly criticised other parents' MMR decisions and decision-making.

CONCLUSIONS

This study corroborated some previous qualitative work but indicated that the shrinking group of parents now rejecting MMR comprises mainly those with more extreme and complex anti-immunisation views, whilst parents opting for single vaccines may use second-hand information about the controversy. In response, policymakers and practitioners should revise their expectations of today's MMR decision-makers, and their methods for supporting them.

Acceptance on the move: public reaction to shifting vaccination realities

This review examines four events related to vaccination that have occurred in recent years: (a) the ongoing recovery from the MMR/Autism scare in the UK, (b) the upgrading of the Varicella vaccine to a universal childhood vaccine, (c) the major effort of authorities to provide a vaccine for A/H1N1 influenza and its rejection by the public, and, d) the current attempts to change the HPV vaccine target from girls only to boys and girls. All of these changes have been met with shifts in the public acceptance of the relevant vaccine. These shifts are characterized not only by the number of people willing to be vaccinated, but also by the attitudes and the motives related to acceptance. Examination of the interrelationship between changes in vaccination realities, and changes in acceptance patterns suggests that today, the public has a better understanding of vaccination, is acting in a more reflexive way, and is capable of changing attitudes and behavior. All together, changes in vaccination enhance debates and dialogues about vaccines, and lead to higher awareness and more conscious acceptance.

Attitudinal and demographic predictors of measles-mumps-rubella vaccine (MMR) uptake during the UK catch-up campaign 2008-09: cross-sectional survey

Background and Objective

Continued suboptimal measles-mumps-rubella (MMR) vaccine uptake has re-established measles epidemic risk, prompting a UK catch-up campaign in 2008–09 for children who missed MMR doses at scheduled age. Predictors of vaccine uptake during catch-ups are poorly understood, however evidence from routine schedule uptake suggests demographics and attitudes may be central. This work explored this hypothesis using a robust evidence-based measure.

Design

Cross-sectional self-administered questionnaire with objective behavioural outcome.

Setting and Participants

365 UK parents, whose children were aged 5–18 years and had received <2 MMR doses before the 2008–09 UK catch-up started.

Main Outcome Measures

Parents' attitudes and demographics, parent-reported receipt of invitation to receive catch-up MMR dose(s), and catch-up MMR uptake according to child's medical record (receipt of MMR doses during year 1 of the catch-up).

Results

Perceived social desirability/benefit of MMR uptake (OR = 1.76, 95% CI = 1.09–2.87) and younger child age (OR = 0.78, 95% CI = 0.68–0.89) were the only independent predictors of catch-up MMR uptake in the sample overall. Uptake predictors differed by whether the child had received 0 MMR doses or 1 MMR dose before the catch-up. Receipt of catch-up invitation predicted uptake only in the 0 dose group (OR = 3.45, 95% CI = 1.18–10.05), whilst perceived social desirability/benefit of MMR uptake predicted uptake only in the 1 dose group (OR = 9.61, 95% CI = 2.57–35.97). Attitudes and demographics explained only 28% of MMR uptake in the 0 dose group compared with 61% in the 1 dose group.

Conclusions

Catch-up MMR invitations may effectively move children from 0 to 1 MMR doses (unimmunised to partially immunised), whilst attitudinal interventions highlighting social benefits of MMR may effectively move children from 1 to 2 MMR doses (partially to fully immunised). Older children may be best targeted through school-based programmes. A formal evaluation element should be incorporated into future catch-up campaigns to inform their continuing improvement.