Nudges or mandates? The ethics of mandatory flu vaccination

Does Experience of Vaccination Improve Vaccine Confidence and Trust? Policy Feedback Effects of Mass COVID-19 Vaccination in the United States

CONTEXT

Policy feedback research has demonstrated that a highly tangible policy that shapes public attitudes through direct and day-to-day experiences often reshapes public opinion, with the effect of generating supportive or skeptical constituencies that determine the sustainability of future programs. This article examines the impact of mass vaccination efforts on attitudes toward vaccines in a context of high vaccine hesitancy in the United States.

METHODS

The authors analyzed 73,092 survey responses from 9,229 participants in the longitudinal data from the Understanding America Study project, covering December 2020 to July 2023. Using two-way fixed-effects ordinary least squares regression and ordinal logistic regression, the authors estimated the changes in attitudes toward vaccines, including trust in vaccine manufacturing and approval processes, following COVID-19 vaccinations.

FINDINGS

COVID-19 vaccination was associated with improved perceptions of vaccine effectiveness and social benefits and reduced mistrust in vaccine-related processes. However, it did not significantly alleviate concerns regarding vaccine side effects and severe illness stemming from vaccination. The strongest effects were observed among initially hesitant respondents who eventually received vaccinations.

CONCLUSIONS

The experience of COVID-19 vaccination generally improved attitudes and confidence in COVID-19 vaccines among the US public, particularly among vaccine-hesitant people. These effects could have positive impacts on future immunization programs by mitigating vaccine hesitancy.

A systemic evaluation of COVID-19 vaccination drives in LICs, LMICs, UMICs, and HICs: Preparedness for future pandemics

Introduction

The COVID-19 pandemic has significantly impacted global healthcare systems. Vaccination is an effective strategy to battle the disease. Policies and distribution frameworks have varied widely across countries. The paper aims to highlight the global vaccination trends in these nations, based on their economic classification, which will illuminate key takeaways that will allow for better pandemic management policies.

Methods

A list of the most populated countries across each income slab was drawn up, and information on their vaccination campaigns was collected from national government portals and official health department websites of these countries in a structured manner. Data collected for the attributes was qualitatively described and converted into binary responses for quantitative analysis. ANOVA test, Chi-square test, and regression models were employed.

Results

A consistent decreasing trend was noted in the percentage of the population vaccinated as the spectrum from higher-income countries to lower-income countries was traversed for all dose statuses. Fewer types of vaccines were available in the lower-income countries. Though compliance with the CDC vaccination strategies guide was largely noted, a linear regression univariate analysis of vaccination drive parameters carried out for single-dose vaccination yielded statistically significant results for medical provider vaccine standardization (P-value = 0.002), vaccination requirements (P-values <0.001), and provider recommendation. (P-values <0.001) Vaccine hesitancy was not dependent on economic status.

Conclusion

Concerted global initiatives like vaccine donation would assist efforts in mitigating disease spread. Prompt busting of baseless anti-vaccine narratives and strengthening healthcare infrastructure to meet national requirements should be given due importance.

The Promise and Potential of Metal-Organic Frameworks and Covalent Organic Frameworks in Vaccine Nanotechnology

The immune system's complexity and ongoing evolutionary struggle against deleterious pathogens underscore the value of vaccination technologies, which have been bolstering human immunity for over two centuries. Despite noteworthy advancements over these 200 years, three areas remain recalcitrant to improvement owing to the environmental instability of the biomolecules used in vaccines─the challenges of formulating them into controlled release systems, their need for constant refrigeration to avoid loss of efficacy, and the requirement that they be delivered via needle owing to gastrointestinal incompatibility. Nanotechnology, particularly metal-organic frameworks (MOFs) and covalent organic frameworks (COFs), has emerged as a promising avenue for confronting these challenges, presenting a new frontier in vaccine development. Although these materials have been widely explored in the context of drug delivery, imaging, and cancer immunotherapy, their role in immunology and vaccine-related applications is a recent yet rapidly developing field. This review seeks to elucidate the prospective use of MOFs and COFs for biomaterial stabilization, eliminating the necessity for cold chains, enhancing antigen potency as adjuvants, and potentializing needle-free delivery of vaccines. It provides an expansive and critical viewpoint on this rapidly evolving field of research and emphasizes the vital contribution of chemists in driving further advancements.

Mapping the Cognitive Biases Related to Vaccination: A Scoping Review of the Literature

INTRODUCTION

Human behavior and understanding of the vaccine ecosystem play a critical role in the vaccination decision-making process. The objective of this study was to understand different cognitive biases that may lead to vaccine acceptance or hesitancy.

METHODS

The eligibility criteria for this scoping review was vaccination-related cognitive bias studies published in the English language from inception to April 2022 and available on PubMed, Embase, and Google Scholar. It included all geographical locations and individuals of all age groups and excluded studies focusing on (i) clinical trials of vaccines, (ii) vaccine research conduct bias, (iii) cognitive delay, or (iv) statistical biases. The search method also included reviewing references in the retrieved articles.

RESULTS

Overall, 58 articles were identified, and after screening, 19 were included in this study. Twenty-one cognitive biases with the potential to affect vaccination decision-making were observed. These biases were further grouped into three broad categories: cognitive biases seen while processing vaccine-related information, during vaccination-related decision-making, and due to prior beliefs regarding vaccination.

CONCLUSIONS

This review identified critical cognitive biases affecting the entire process of vaccination that can influence research and public health efforts both positively and negatively. Recognizing and mitigating these cognitive biases is crucial for maintaining the population's level of trust in vaccination programs around the world.

A survey of university students on attitudes, behaviors, and intentions toward influenza vaccination

Objective To determine attitudes, behaviors, and intentions of university students regarding influenza vaccination.ParticipantsUndergraduate, graduate, and professional students enrolled at a private, midwestern university.Methods A 24-item electronic survey was designed and distributed after literature review and inputs from experts on immunizations. Bivariate tests were performed to observe differences between various subgroups of respondents (age, gender, race/ethnicity, housing, and academic program). Multivariate logistic regression was performed to find associations with their vaccination preferences.Results Of 3,267 complete responses (36.3% of total students), 75% reported obtaining influenza vaccination in 2016-2017. Vaccination rates were highest for Asian (81.0%) and lowest for Black students (59.6%). Health professional student vaccination rates of 89.3% were achieved with a vaccination mandate in place. Lowest immunization rates were identified for law (47.1%) and business (52.7%) students. Positive promotional factors were identified.Conclusions Access to free, on-campus vaccinations, mandates and promotional efforts are associated with high influenza vaccination rates.

Influenza vaccination from the perspective of health care workers at university hospitals

BACKGROUND

The influenza vaccination rate of healthcare workers (HWs) in Poland is low. Before implementing methods for promoting influenza vaccination, it is crucial to identify attitudes towards vaccination. We aimed to examine the knowledge and attitudes towards influenza vaccination of HWs at university hospitals. Moreover, we evaluated the incentives for getting influenza vaccination among HWs.

METHODS

From September 2020 to October 2020, we surveyed HWs in one children's hospital and two adults' hospitals in Warsaw (Poland). We included only fully and correctly completed surveys into final analysis.

RESULTS

A total of 950 questionnaires (85% women, 45% <40 years old, 33% physicians and 48% nurses, 56% working in a children's hospital) were evaluated. Of all HWs, 25% declared they were vaccinated and 54% planned to get vaccinated in the next season. We have analyzed attitudes towards influenza vaccination and motivations to get vaccinated.

CONCLUSIONS

Among HWs in academic hospitals, males, people <40 years old, physicians and those working in children's hospital are more likely to get vaccinated and their attitudes towards influenza vaccination are more positive. Of those less likely to get vaccinated, people >40 years old and nurses could be effectively persuaded by free and on-site influenza vaccination. Moreover, free access to vaccination is the strongest motivator for vaccination among all HWs. The attitudes towards mandatory influenza vaccination differ sharply among HWs-while physicians are ready to accept it, nurses are not.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04569019.

How Scientists View Vaccine Hesitancy

This paper examines possible causes, consequences, and potential solutions for addressing vaccine hesitancy in the United States, focusing on the perspectives of academic scientists. By examining the experiences of scientists, who are arguably a critical community in US society, we gain deeper insights into how they understand the complexities of vaccine hesitancy and whether their insights and opinions converge with or diverge from the current literature. We present findings from a national survey of a representative sample of academic scientists from the fields of biology and public health regarding vaccine hesitancy and related topics. Empirical analysis using descriptive, bivariate, and multivariate analyses covers multiple topics, including vaccine controversy, trust in science, causes of vaccine hesitancy, preferred policy and regulatory approaches, risk perceptions, and scientists' ethics and perceived communication roles. The results highlight a diversity of opinions within the scientific community regarding how to improve science-society communication in regard to vaccines, including the need to be transparent and candid to the public about the risk of vaccines and their research.

How does nudging the COVID-19 vaccine play out in people who are in doubt about vaccination?

In spite of the growing availability of COVID-19 vaccines, a substantial number of people is reluctant or uncertain about getting the vaccine. Nudges may improve vaccine uptake but it is unclear how this plays out with the experience of autonomous choice, decision competence, decision satisfaction, and being pressured to make a choice. In an online experiment among a representative sample (N = 884), we examined whether a social norm nudge or a default nudge (either or not transparent) was effective in steering the desired choice of making a hypothetical early vaccination appointment as compared to making a later appointment or no appointment. We also examined how both nudges affected autonomy and related downstream consequences. None of the nudges proved effective in making the desired choice of early vaccination and neither did they impact on downstream consequences. Rather, our results indicate that participants who were certain about their choice (i.e., opted for the earliest available vaccination opportunity or not getting vaccinated at all) reported higher levels of autonomy, competence and satisfaction than participants who did not know yet about vaccination or who postponed the moment of getting their vaccination. We conclude that the experience of autonomy and related downstream consequences is determined by having made up one's mind about vaccination, and is not affected by attempts to nudge the individual.

Willingness to receive a vaccine is influenced by adverse events following immunisation experienced by others

An adverse event following immunization (AEFI) can have consequences for an individual's future decision making and may contribute to vaccine hesitancy. AEFIs vary in severity and can be experienced directly (by an individual themselves) or indirectly (through witnessed or recounted events). We sought to measure the prevalence of specific AEFIs and understand which AEFIs have the greatest associations with reduced willingness to receive a vaccine and how injection anxiety may moderate the relationship. We conducted a cross-sectional online survey with both qualitative and quantitative elements in a sample of adults aged 18 years and over in Australia. Nineteen percent of the 1050 respondents reported experiencing an AEFI that they found stressful. Those who experienced an AEFI reported significantly higher levels of injection anxiety than those who did not. Within the group who reported experiencing an AEFI, respondents were significantly less likely to be willing to receive a COVID-19 vaccine if they reported: indirect exposure to an uncommon/rare AEFI compared with other AEFIs (aOR:0.39; 95% CI: 0.18-0.87); indirect exposure to a scientifically unsupported AEFI compared with other AEFIs (aOR:0.18; 95% CI: 0.05-0.57). Direct exposure to an AEFI was not associated with willingness to receive a COVID-19 vaccine. For those who reported experiencing an AEFI, the odds of willingness to receive a COVID-19 vaccine decreased significantly with an increase in injection anxiety (aOR:0.94; 95% CI: 0.9-0.98). Our results suggest that more is needed to mitigate the consequences of AEFIs on vaccine willingness. Empathically acknowledging at a community level, the experience of both real and perceived AEFIs and incorporating accounts of positive vaccination experiences in vaccine hesitancy interventions may be useful.

Acceptability rate and barriers to COVID-19 vaccination among healthcare workers in Chukwuemeka Odumegwu Ojukwu University Teaching Hospital, Amaku-Awka, Nigeria

Background

Healthcare workers were at the forefront of the COVID-19 pandemic. The acceptability and uptake of COVID-19 vaccines among healthcare workers was an important strategy in halting the spread of the virus as well as the antecedent implications on global health and the world economy.

Objectives

This study aims to determine the acceptability rate and barriers to COVID-19 vaccination of frontline healthcare workers in Awka, Nigeria.

Design

This is an analytical cross-sectional study.

Methods

An online cross-sectional survey was conducted from February 2022 to April 2022 to obtain the data for this study. One hundred healthcare workers were studied. Acceptability rate and barriers to uptake of COVID-19 vaccination were outcome measures.

Results

The COVID-19 vaccination rate was 45.0% among healthcare workers in study area of Awka metropolis. Ages 30-39 years had the highest acceptance rate of COVID-19 vaccination, 19 (47.5%; p = 0.262) with a more female preponderance of COVID-19 vaccine acceptance compared to males [26 (41.3%) vs 16 (42.2%), p = 0.721]. The place of residence of respondents (urban vs rural) and their marital status (married vs single) appeared not to influence the acceptance of COVID-19 vaccination [(38 (42.2%) vs 3 (33.3%); p = 0.667; 25 (36.8% vs 17 (54.8%); p = 0.433)]. Years of work experience (<10 years vs >10 years) significantly affected COVID-19 vaccine acceptance [27 (45.8%) vs 12 (52.2%); p = 0.029]. Educational status and monthly income appeared not to influence vaccine uptake (p > 0.05, for both). A significant number of respondents were not sure why they should or should not take the COVID-19 vaccine [49 (92.5%) vs 35 (83.3%); p = 0.001].

Conclusion

The COVID-19 vaccination rate is still poor among healthcare workers in Awka metropolis. The majority of respondents do not know why they should or should not take COVID-19 vaccine. We therefore recommend robust awareness campaigns that will explain in clear terms the essence and efficacy of COVID-19 vaccination in order to improve vaccine acceptance.

Trustworthiness of information sources on vaccines for COVID-19 prevention among Brazilians

OBJECTIVE

This study aims to assess the trustworthiness of information sources, perception of clear information about the vaccine, and strategies to increase adherence to vaccination to provide managers with information that helps establish effective communication with the population about vaccination.

METHOD

This is an online survey conducted between January 22 and 29, 2021, preceded by an Informed Consent, that aims to assess vaccine hesitancy, which corresponded to the first week of vaccination initiation to prevent COVID-19 in Brazil. Data were obtained from a questionnaire made available through a free platform and stored in Google Forms and later exported to the SPSS statistical package for analysis. The sample consisted of all questionnaires from participants who self-declared as age 18 or older, Brazilian, and residing in Brazil at the time of the survey. Incomplete records with more than 50% of blank items and duplicates were excluded. All categorical variables were analyzed from their absolute and relative frequencies. Multivariate logistic regression was performed to verify the relationship between dependent variables and independent variables.

RESULTS

The results show that trust in information sources diverges between hesitant and non-hesitant. They also showed that some participants show an overall distrust that seems to have deeper foundations than issues related only to the source of information. The high rejection of television and the WHO as sources of information among hesitant suggests that integrated actions with research institutes, public figures vaccinating, and religious leaders can help to combat vaccine hesitation. Two actors become particularly important in this dynamic, both for good and bad, and their anti-vaxxer behavior must be observed: the doctor and the Ministry of Health.

CONCLUSION

This study contributes to gathering valuable information to help understand the behavior and thinking relevant to the adherence to vaccination recommendations.

An empirical assessment of the factors influencing acceptance of COVID-19 vaccine uptake between Kenyan and Hungarian residing populations: A cross-sectional study

The development of effective, safe, and acceptable vaccines is a long process. COVID-19 vaccine hesitancy continues to elicit mixed reactions among different quarters despite numerous evidence of their effectiveness. This study aimed to determine the availability and acceptance rates of SARS-CoV-2 vaccines, among Kenyan and Hungarian residing populations and the underlying reasons contributing to the hesitancy of uptake. A non-probability, snowball sampling design was employed, and a survey questionnaire tool link was expeditiously disseminated. Data were carefully analyzed descriptively. Demographic variables, COVID-19 awareness, possible exposure, reasons associated with hesitancy in taking up a vaccine, choice of a vaccine, and availability of vaccines among other important variables were tested to explore their associations with vaccine acceptance rates between the two distinct countries. A total of 1960 participants were successfully enrolled in the research study, while 67 participants were excluded based on the inclusion criterion set. There was, however, no significant difference in COVID-19 public awareness between the Kenyan and Hungarian-residing participants, p = 0.300. Of the respondents, 62.4% were willing and ready to receive vaccines against COVID-19 disease. There was a significant difference (p = 0.014) between the Kenyan and Hungarian-residing respondents concerning vaccine uptake and acceptance rates. The vaccine acceptance rates in Hungary were higher than in Kenya, with mean = 0.27, SD = 0.446, S. E = 0.045 for the Hungarian population sample and mean = 0.40, SD = 0.492, S. E = 0.026, for the Kenyan sample respectively. Concerning gender and vaccine acceptance, there was a notable significant difference between males and females, p = 0.001, where the mean for males and females were 0.29 and 0.46 respectively. Acceptance rates among males were higher than among females. The functions of One-Way ANOVA and Chi-square were used to establish any significant differences and associations between means and variables respectively. Concerns regarding the safety, efficacy, and accuracy of information about the developed vaccines are significant factors that must be promptly addressed, to arrest crises revolving around COVID-19 vaccine hesitancy, especially in Kenya and among females in both populations, where acceptance rates were lower. Expansion of the screening program to incorporate antibody (serology) tests, is also highly recommended in the present circumstance. Equitable distribution of vaccines globally should be encouraged and promoted to adequately cover low- and middle-income countries. To enhance effective combat on vaccination hesitancy and apprehension in different countries, mitigation techniques unique to those countries must be adopted.

Reducing COVID vaccine hesitancy by inducing a comparative mindset

OBJECTIVE

To investigate if a behavioral nudge comprising a vaccination opportunity that employs a comparative probe first (i.e., which vaccine to take) versus the more commonly-used deliberative probe (i.e., willingness to take a vaccine), reduces vaccine hesitancy, while controlling for political partisanship.

METHODS

In a randomized study, conducted on Amazon Mechanical Turk and Prolific, we varied the manner in which the vaccination offer is posed. In one group, participants were asked to compare which vaccine they would like to take (i.e., the comparative probe), while, in another group, participants were asked to deliberate whether they would like to take the vaccine (i.e., the deliberative probe). Participants' political preferences were also measured. The primary outcome variable was vaccine hesitancy.

RESULTS

A LOGIT regression (N = 1736), was conducted to test the research questions. Overall, the comparative probe yielded a 6% reduction in vaccine hesitancy relative to the typical deliberative probe. Additionally, while vaccine hesitancy varies due to individual political views, the comparative probe is effective at reducing vaccine hesitancy even among the most vaccine hesitant population (i.e., Pro-Trump Republicans) by almost 10% on average.

CONCLUSIONS

Subtly changing the manner in which the vaccination offer is framed, by asking people to compare which vaccine to take, and not deliberate about whether they would like to take a vaccine, can reduce vaccine hesitancy, without being psychologically taxing or curtailing individuals' freedom to choose. The nudge is especially effective among highly vaccine hesitant populations such as Pro-Trump Republicans. Our results suggest a costless communication protocol in face-to-face interactions on doorsteps, in clinics, in Pro-Trump regions and in the mass media, that might protect 5 million Americans from COVID-19.

"I'm luckier than everybody else!": Optimistic bias, COVID-19 conspiracy beliefs, vaccination status, and the link with the time spent online, anticipated regret, and the perceived threat

The catastrophic wave in the fall of 2021 drove Romania to the top of the list of dangerous COVID-19 infections, with the highest mortality rate in Europe. At the same time, Romania had one of the lowest vaccination rates. In this context, the present research aimed to explore the link between vaccination intention/status, optimistic bias, COVID-19 conspiracy beliefs, the time spent online, and vaccination (anticipated) regret. Our convenience sample was formed by 408 adults aged 18-63 years (M = 22.11, SD = 6.18, 69.9 % females), who were distributed into four groups: (1) non-vaccinated who definitely refused COVID-19 vaccination, (2) non-vaccinated who considered COVID-19 vaccination, (3) non-vaccinated who reported their absolute willingness to COVID-19 vaccination, and (4) people who were COVID-19 vaccinated. We conducted our analyses separately, depending on these groups (i.e., vaccination intentions/status). Data were collected using an online questionnaire between November 10, 2021, and January 03, 2022. In our cross-sectional approach, following correlation and ANOVA analyses, among the observed patterns were (1) the significant negative relation between optimism bias and the perceived COVID-19 threat; (2) the positive link between anticipated regret, post-vaccination regret, age, and conspiracy beliefs. We discuss our findings considering their contribution to health policies and practices.

Role of Occupational Health Services in Planning and Implementing of Staff COVID-19 Vaccination Clinic: A Tertiary Hospital Experience in Singapore

CONTEXT

Healthcare workers all over the world were prioritized for vaccination against COVID-19 in view of the high-risk nature of their job scopes when vaccines were first available in late 2020. Vaccine hesitancy was an important problem to tackle in order to achieve a high vaccination rate, especially for vaccines that were developed using mRNA technology. We aimed to use the '3Cs' model to address vaccine hesitancy to ensure maximal uptake of the Pfizer-BioNTech vaccine among healthcare workers in a tertiary hospital in Singapore.

METHODS

Various measures were used to reduce the confidence, complacency, and convenience barriers. The staff vaccination clinic was on-site and centralized, with appointments given in advance to ensure vaccine availability and to reduce wait time, providing convenience to staff. Direct and repeated communications with the staff via multiple channels were used to address vaccine safety and efficacy so as to promote confidence in the vaccines and overcome complacency barriers. To further encourage staff to get vaccinated, staff were allowed time off for vaccination when at work. Staff with a high risk of exposure to COVID-19 or those caring for immunocompromised patients were prioritized to take the vaccines first. The collection of data on adverse events was via on-site monitoring and consultation at Occupational Health Clinic (OHC).

RESULTS

Nearly 80% of staff had completed vaccination when the vaccination exercise ended at the end of March 2021. With the loosening of the contraindications to vaccination over time, staff vaccination rates reached 89.3% in early July and nearly 99.9% by the end of the year. No major or serious vaccine-related medication or administration errors were reported. No staff had anaphylaxis.

CONCLUSIONS

By using the '3Cs' model to plan out the vaccination exercise, it is possible to achieve a high vaccination rate coupled with effective and customized communications. This multi-disciplinary team approach can be adapted to guide vaccination efforts in various settings in future pandemics.

Italian health professionals on the mandatory COVID-19 vaccine: An online cross-sectional survey

Italy was the first country in Europe to make vaccination against COVID-19 mandatory for healthcare professionals by imposing restrictions in cases of non-compliance. This study investigates the opinions of the Italian healthcare professionals' categories affected by the regulation. We performed a qualitative online survey: the questionnaire comprised both close- and open-ended questions. The final dataset included n = 4,677 valid responses. Responses to closed-ended questions were analyzed with descriptive statistics. The framework method was applied for analyzing the open-ended questions. The sample spanned all health professions subject to compulsory vaccination, with a prevalence of physicians (43.8%) and nurses (26.3%). The vaccine adhesion before the introduction of the obligation was substantial. 10.4% declared not to have adhered to the vaccination proposal. Thirty-five percent of HPs who opted not to get vaccinated said they experienced consequences related to their choice. The trust in the vaccine seems slightly cracked, demonstrating overall vaccine confidence among professionals. Nonetheless, our results show that whether (or not) professionals adhere to vaccination is not a reliable indicator of consent to how it was achieved. There are criticisms about the lawfulness of the obligation. The data show a great variety of participants interpreting their roles concerning public and individual ethics. The scientific evidence motivates ethics-related decisions-the epidemic of confusing and incorrect information affected professionals. The Law triggered an increased disaffection with the health system and conflicts between professionals. Dealing with the working climate should be a commitment to assume soon.

Healthcare workers' acceptability of influenza vaccination nudges: Evaluation of a real-world intervention

Nudges have been proposed as an effective tool to stimulate influenza vaccination uptake in healthcare workers. However, the success of such nudges in practice is heavily reliant on their acceptance by the intended healthcare worker population, which has not been thoroughly examined to date. This study investigated healthcare workers’ acceptability of diverse influenza vaccination nudges implemented in a real-world vaccination campaign and explored the relationship between nudge acceptability and vaccination uptake. A cross-sectional study was conducted among 244 Dutch hospital employees, following a hospital-wide influenza vaccination nudging intervention. A survey assessed healthcare workers’ perceived acceptability of ten distinct influenza vaccination nudges, along with their vaccination status and relevant covariates (e.g., general perceptions regarding influenza vaccination of healthcare workers). Influenza vaccination nudges in general were deemed acceptable, with reward-based nudges being the least accepted, while digital vaccination forms, a mobile vaccination post, peer vaccination, and digital vaccination reminders were most appreciated. A higher overall acceptance of these nudges was associated with a greater likelihood of being vaccinated, particularly in healthcare workers with favorable perceptions of influenza vaccination usefulness. Our findings suggest that influenza vaccination nudges are an accepted means to systematically promote immunization of healthcare workers, and thus present a viable strategy for public health policies aimed at this group.

An (un)healthy social dilemma: a normative messaging field experiment with flu vaccinations

BACKGROUND

Influenza seasons can be unpredictable and have the potential to rapidly affect populations, especially in crowded areas. Prior research suggests that normative messaging can be used to increase voluntary provision of public goods, such as the influenza vaccine. We extend the literature by examining the influence of normative messaging on the decision to get vaccinated against influenza.

METHODS

We conduct a field experiment in conjunction with University Health Services, targeting undergraduate students living on campus. We use four posters, randomized by living area clusters to advertise flu vaccination clinics during the Fall. The wording on the posters is varied to emphasize the individual benefits of the vaccine, the social benefits of the vaccine or both benefits together. We collect survey data for those vaccinated at the vaccination clinics, and for those not vaccinated via an online survey.

RESULTS

We find that any normative message increases the percentage of students getting the flu vaccine compared with no message. In terms of the likelihood of getting the flu vaccine, emphasizing both the individual and social benefits of vaccination has the largest increase in the vaccination rate (19-20 percentage point increase). However, flu vaccinations did not reach the herd immunity threshold (70% of students vaccinated).

CONCLUSIONS

This study provides evidence that there is a pro-social component that is relevant in individual vaccination decisions which should be accounted for when designing vaccination campaigns. The results of this normative, pro-social messaging experiment could be extended to other at-risk communities where the number of background risks is much larger. This is especially relevant nowadays, as other seasonal vaccines are being rolled out and younger adults are the ones with the lowest uptake.

Revisiting COVID-19 vaccine hesitancy around the world using data from 23 countries in 2021

The COVID-19 pandemic continues to impact daily life, including health system operations, despite the availability of vaccines that are effective in greatly reducing the risks of death and severe disease. Misperceptions of COVID-19 vaccine safety, efficacy, risks, and mistrust in institutions responsible for vaccination campaigns have been reported as factors contributing to vaccine hesitancy. This study investigated COVID-19 vaccine hesitancy globally in June 2021. Nationally representative samples of 1,000 individuals from 23 countries were surveyed. Data were analyzed descriptively, and weighted multivariable logistic regressions were used to explore associations with vaccine hesitancy. Here, we show that more than three-fourths (75.2%) of the 23,000 respondents report vaccine acceptance, up from 71.5% one year earlier. Across all countries, vaccine hesitancy is associated with a lack of trust in COVID-19 vaccine safety and science, and skepticism about its efficacy. Vaccine hesitant respondents are also highly resistant to required proof of vaccination; 31.7%, 20%, 15%, and 14.8% approve requiring it for access to international travel, indoor activities, employment, and public schools, respectively. For ongoing COVID-19 vaccination campaigns to succeed in improving coverage going forward, substantial challenges remain to be overcome. These include increasing vaccination among those reporting lower vaccine confidence in addition to expanding vaccine access in low- and middle-income countries.

Vaccine Hesitancy and Cognitive Biases: Evidence for tailored communication with parents

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The model to analyse vaccine hesitancy should include the evaluation of cognitive biases.

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Communication interventions should be tailored based on the drivers of parents’ choice.

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Conspiracy mentality and risk propension correlate with the vaccine hesitancy.

Background

Vaccine hesitancy (VH) remains worldwide a reason of concern. Most of the vaccination education strategies followed a “fact-based” approach, based on the assumption that decision making is a rational process, without considering the influence of cognitive biases and heuristics. Our study aimed at identifying factors involved in the parents’ vaccination choice to inform and shape communication interventions.

Methods

We conducted an online national survey among parents between November 2020 and April 2021. The questionnaire consisted of 42 items organised in 4 parts: (1) personal information, (2) cognitive biases and risk propension, (3) Analytic Thinking (Cognitive Reflection Test), (4) conspiracy mentality, health literacy, and VH. Exploratory factor analysis was conducted to identify latent variables underlying the 19 items related to the 6 cognitive biases. Factors were categorised in quintiles and the corresponding pseudo-continuous variables used as predictors of the VH. Logistic regression model was applied to assess the association of the VH with factors, conspiracy mentality and risk propension. We adjusted for age, gender, economic status, and education levels.

Results

The study included 939 parents, 764 women (81.4%), 69.8% had a degree or higher level of education. Considering cognitive biases, four factors explaining 54% of the total variance were identified and characterised as: fear of the side effects of vaccines (scepticism factor); carelessness of the risk and consequences of infections (denial factor); optimistic attitude (optimistic bias factor); preference for natural products (naturalness bias factor). All factors were positively associated to VH (p < 0.001) as were conspiracy mentality (p = 0.007) and risk propension (p = 0.002).

Conclusions

This study confirmed the need to amplify the model used to analyse the VH considering cognitive biases as important factor affecting the parents’ decision making. These results may be useful to design personalised communication interventions regarding vaccines and vaccination.

Impact of COVID-19 vaccine-associated side effects on health care worker absenteeism and future booster vaccination

BACKGROUND

Short-term side effects related to mRNA vaccines against SARS-CoV-2 are frequent and bothersome, with the potential to disrupt work duties and impact future vaccine decision-making.

OBJECTIVE

To identify factors more likely to lead to vaccine-associated work disruption, employee absenteeism, and future vaccine reluctance among healthcare workers (HCWs).

HYPOTHESIS

Side effects related to COVID vaccination: 1- frequently disrupt HCW duties, 2- result in a significant proportion of HCW absenteeism, 3- contribute to uncertainty about future booster vaccination, 4- vary based on certain demographic, socioeconomic, occupational, and vaccine-related factors.

METHODS

Using an anonymous, voluntary electronic survey, we obtained responses from a large, heterogeneous sample of COVID-19-vaccinated HCWs in two healthcare systems in Southern California. Descriptive statistics and regression models were utilized to evaluate the research questions.

RESULTS

Among 2,103 vaccinated HCWs, 579 (27.5%) reported that vaccine-related symptoms disrupted their professional responsibilities, and 380 (18.1%) missed work as a result. Independent predictors for absenteeism included experiencing generalized and work-disruptive symptoms, and receiving the Moderna vaccine [OR = 1.77 (95% CI = 1.33 - 2.36), p < 0.001]. Physicians were less likely to miss work due to side effects (6.7% vs 21.2% for all other HCWs, p < 0.001). Independent predictors of reluctance toward future booster vaccination included lower education level, younger age, having received the Moderna vaccine, and missing work due to vaccine-related symptoms.

CONCLUSION

Symptoms related to mRNA vaccinations against SARS-CoV-2 may frequently disrupt work duties, lead to absenteeism, and impact future vaccine decision-making. This may be more common in Moderna recipients and less likely among physicians. Accordingly, health employers should schedule future booster vaccination cycles to minimize loss of work productivity.

Ethics of vaccine refusal

Proponents of vaccine mandates typically claim that everyone who can be vaccinated has a moral or ethical obligation to do so for the sake of those who cannot be vaccinated, or in the interest of public health. I evaluate several previously undertheorised premises implicit to the 'obligation to vaccinate' type of arguments and show that the general conclusion is false: there is neither a moral obligation to vaccinate nor a sound ethical basis to mandate vaccination under any circumstances, even for hypothetical vaccines that are medically risk-free. Agent autonomy with respect to self-constitution has absolute normative priority over reduction or elimination of the associated risks to life. In practical terms, mandatory vaccination amounts to discrimination against healthy, innate biological characteristics, which goes against the established ethical norms and is also defeasible a priori.

Attitudes, beliefs and practice of Egyptian healthcare workers towards seasonal influenza vaccination

BACKGROUND

Seasonal influenza vaccination is highly recommended for healthcare workers (HCWs) every year to protect them and reduce the risk of disease transmission at workplaces. Relatively few studies addressed influenza vaccination in the Eastern Mediterranean Region.

OBJECTIVES

The main objective of this study was to explore the attitudes, beliefs and practice of Egyptian HCWs towards seasonal influenza vaccine.

METHODS

This is a nationwide cross-sectional study. Data were collected through self-administered structured questionnaire. A sample of 3534 HCWs (physicians and nurses) was collected from different levels of healthcare facilities.

RESULTS

The proportion of seasonal influenza vaccine uptake during the last season was 30.7% while the percentage of ever vaccinated was 46.8%. The most identified reason for non-compliance was lack of trust about vaccine efficacy and its adverse events. Around 80% of participants expressed positive attitude towards influenza vaccine and the vast majority (98%) agreed to uptake the vaccine during pandemic. There was significant positive association between attitude score and influenza vaccine uptake. Raising awareness about vaccine and ensuring vaccine availability were the main suggestions by HCWs to improve vaccine uptake.

CONCLUSIONS

Although there was positive attitude towards influenza vaccine, yet vaccination coverage was suboptimal particularly among those working in university hospitals. Educational messages and operational strategies addressing motivators and barriers that emerged from this study are needed to optimize vaccine uptake.

Nudging influenza vaccination among health care workers

Our online randomized controlled trial on 6230 healthcare workers (HCWs) tests the impact that three nudges - social norms, reminding the impact on beneficiaries, and defaults - have on the intention to vaccinate against seasonal influenza across job families. Willingness to get a flu shot was higher among subjects invited to imagine themselves working at the local health authority (LHA) with the greatest immunization coverage within their region relative to their counterparts prompted to imagine working at the LHA with the lowest coverage. Reminding the impact of flu vaccination on beneficiaries had different effects across job families, with physicians caring more benefits for themselves, nurses about patients' benefits, and technicians about family and friends. Default responses anchoring toward a high rather than a low vaccination intention increased the willingness to immunize among all HCW except physicians. Targeted nudges can be considered in developing interventions to promote influenza vaccination among HCWs.

Vaccine hesitancy: evidence from an adverse events following immunization database, and the role of cognitive biases

BACKGROUND

Vaccine hesitancy has been a growing challenge for public health in recent decades. Among factors contributing to vaccine hesitancy, concerns regarding vaccine safety and Adverse Events (AEs) play the leading role. Moreover, cognitive biases are critical in connecting such concerns to vaccine hesitancy behaviors, but their role has not been comprehensively studied. In this study, our first objective is to address concerns regarding vaccine AEs to increase vaccine acceptance. Our second objective is to identify the potential cognitive biases connecting vaccine hesitancy concerns to vaccine-hesitant behaviors and identify the mechanism they get triggered in the vaccine decision-making process.

METHODS

First, to mitigate concerns regarding AEs, we quantitatively analyzed the U.S. Vaccine Adverse Event Reporting System (VAERS) from 2011 to 2018 and provided evidence regarding the non-severity of the AEs that can be used as a communicable summary to increase vaccine acceptance. Second, we focused on the vaccination decision-making process. We reviewed cognitive biases and vaccine hesitancy literature to identify the most potential cognitive biases that affect vaccine hesitancy and categorized them adopting the Precaution Adoption Process Model (PAPM).

RESULTS

Our results show that the top frequent AEs are expected mild reactions like injection site erythema (4.29%), pyrexia (3.66%), and injection site swelling (3.21%). 94.5% of the reports are not serious and the average population-based serious reporting rate over the 8 years was 25.3 reports per 1 million population. We also identified 15 potential cognitive biases that might affect people's vaccination decision-making and nudge them toward vaccine hesitancy. We categorized these biases based on the factors that trigger them and discussed how they contribute to vaccine hesitancy.

CONCLUSIONS

This paper provided an evidence-based communicable summary of VAERS. As the most trusted sources of vaccine information, health practitioners can use this summary to provide evidence-based vaccine information to vaccine decision-makers (patients/parents) and mitigate concerns over vaccine safety and AEs. In addition, we identified 15 potential cognitive biases that might affect the vaccination decision-making process and nudge people toward vaccine hesitancy. Any plan, intervention, and message to increase vaccination uptake should be modified to decrease the effect of these potential cognitive biases.

Enablers and barriers to COVID-19 vaccine uptake: An international study of perceptions and intentions

The development of COVID-19 vaccines is occurring at unprecedented speeds, but require high coverage rates to be successful. This research examines individuals’ psychological beliefs that may act as enablers and barriers to vaccination intentions. Using the health beliefs model as a guide to our conceptual framework, we explore factors influencing vaccine hesitancy and health beliefs regarding risks and severity of the disease, along with individual variables such as income, age, religion, altruism, and collectivism. A questionnaire using newly created measures for various antecedents provided 4303 usable responses from Australia, Canada, England, New Zealand, and the United States. A factor analytic and structural equation model indicates that trust in vaccine approval, the perceived effectiveness of the vaccine for protecting others, and conspiracy beliefs are the most significant drivers of intentions to vaccinate. Older people, those seeking employment, and those who have received a recent influenza vaccine are more likely to be vaccinated against COVID-19. The findings have implications for improving communication strategies targeting individuals about the merits of vaccination, particularly focusing on younger individuals and expanded message framing to include altruistic considerations, and to improve government transparency regarding the effectiveness and side effects of vaccines.

COVID-19 Vaccine Acceptance in Azuay Province, Ecuador: A Cross-Sectional Online Survey

We investigated the COVID-19 vaccination acceptance level in Azuay province, Ecuador through an online survey from 12th to 26th February (before the start of the COVID-19 vaccination campaign in Ecuador). Overall, 1219 respondents participated in the survey. The mean age was 32 ± 13 years; 693 participants (57%) were female. In total, 1109 (91%) of the participants indicated they were willing to be vaccinated with a COVID-19 vaccine, if the vaccine is at least 95% effective; 835 (68.5%) if it is 90% effective and 493 (40.5%) if it is 70% effective; 676 (55.5%) participants indicated they feared side effects and 237 (19.4%) thought the vaccine was not effective. Older age, having had a postgraduate education, a history of a negative COVID-19 test, a high level of worry of contracting COVID-19, believing that COVID-19 infection can be prevented with a vaccine and understanding there is currently an effective vaccine against COVID-19 were associated with higher vaccination acceptance. A vaccination education campaign will be needed to increase the knowledge of Ecuadorians about the COVID-19 vaccine and to increase their trust in the vaccine. People with a lower education level and living in rural areas may need to be targeted during such a campaign.

COVID-19 Vaccination Intentions: The Theory of Planned Behavior, Optimistic Bias, and Anticipated Regret

High vaccination rates within the general population are essential for overcoming the current COVID-19 pandemic. The aim of the present study was to investigate intentions to receive a COVID-19 vaccine as well as the predictors of such intentions. A representative sample of the Norwegian population (N = 1,003, 49.5% females, Mage = 47.9, SD = 17.1) filled in an online questionnaire assessing the components of the Theory of planned behavior (attitudes, subjective norms, and perceived behavioral control), as well as optimistic bias and anticipated regret. Results showed that a majority (61.6%) of participants intend to get vaccinated. Regression analysis revealed that intentions were predicted by positive attitudes toward vaccination (β = 0.31, p < 0.001), subjective norms in favor of vaccination in one's family (β = 0.23, p < 0.001), perceived behavioral control (β = 0.09, p < 0.001), and by anticipated net regret (β = 0.32, p < 0.001), explaining 69% (f 2 = 2.23) of the variance in intentions. Optimistic bias did not predict intentions.

The vaccine-condition or vaccination passport and its eventual fit into a broad recommended vaccination framework against COVID-19

It is important to think about the eventual application of a COVID-19 vaccination certificate as an eligibility criterion to carry out certain activities and to discuss in advance the problems that the use of this tool may pose in legal terms. To this end, we must begin by stating the assumptions that would be necessary to justify its implantation, including scientific consensus on the scope of the immunity granted by COVID-19 vaccines, especially in blocking transmission in the community. Likewise, it emphasizes the importance of broadening the view in the sense of internalizing that the passport or vaccination pass constitutes only one of the many options within a rich catalog of possibilities when it comes to reinforcing the recommended vaccination model through incentives adopted in the Vaccination Strategy against COVID-19, including the use of nudging. In any case, if conditionality is installed and expanded to the extent of significantly influencing daily life, it could lead to a kind of indirect obligation, with the risk of dysfunctions in terms of equality and systemic coherence if the public powers do not contribute to clearly define the legal limits beforehand and to drive a process that in itself could be dispersed and disorderly.

Factors Associated with Influenza Vaccination Uptake among U.S. Adults: Focus on Nativity and Race/Ethnicity

To support implementation strategies for upcoming influenza (flu) vaccinations for foreign-born and racial/ethnic minority groups, we analyzed the 2018 National Health Interview Survey (NHIS) database and performed logistic regression to examine the factors associated with, and the interaction between nativity and race/ethnicity in directing flu vaccination rates during the past 12 months (n = 25,045). As a result, we found nativity and race/ethnicity were associated with flu vaccination rates; foreign-born and non-Hispanic black respondents were less likely to take the vaccine than U.S.-born and non-Hispanic white respondents. The odds ratios were largest for the elderly, those working in the healthcare industry, those with health insurance, and those with a usual source of care (ORs = 3.058, 2.871, 2.317, and 2.342, respectively), suggesting that access to healthcare resources is critical for the uptake of the flu vaccine. There was a significant interaction effect between nativity and race/ethnicity. For improving flu vaccination rates, more support is necessary for foreign-born people and racial/ethnic minorities who have lower health insurance rates and usual sources of care than U.S.-born people and non-Hispanic whites, and thus are less able to adequately access healthcare resources in a timely manner.

Attitudes towards influenza and uptake of the flu vaccine: A survey of pharmacy staff working in English hospitals

OBJECTIVES

Pharmacy staff working in hospitals are at risk of contracting and disseminating influenza. Previous research focuses on community pharmacists' attitudes towards influenza and vaccination. This survey investigates the beliefs and attitudes of pharmacists and other pharmacy staff working in English Hospitals regarding influenza and the vaccine and how this relates to vaccine uptake.

METHODS

A self-administered survey was provided to pharmacy staff at three hospitals in the East Midlands of England. Job role, age and vaccination status (vaccinated, intended to be vaccinated, and not vaccinated) were collected alongside ratings of agreement with 20 statements regarding influenza and vaccination using a Likert scale.

RESULTS

170 pharmacy staff responded; 50.6% had been vaccinated, 17.1% intended to be vaccinated and 32.4% were not vaccinated. Increasing age showed a significant (p = 0.017) positive correlation with increased vaccine uptake as did the beliefs that vaccination protects the individual from influenza (p = 0.049) and that vaccination should be mandatory for NHS staff (p = 0.006). Fear of needles and believing their immune system is strong enough to protect against influenza were negatively correlated with vaccine uptake (p = 0.016 and p = 0.010, respectively). Job role was also strongly correlated with vaccine uptake (p = 0.001), with those holding a pharmacy degree more likely to report being vaccinated or intending to be vaccinated compared to all other pharmacy staff groups.

CONCLUSIONS

This is the first survey to focus on vaccine behaviours of all pharmacy staff groups working in hospitals. Current uptake of the influenza vaccine may be increased through engagement of senior pharmacy colleagues and providing education on influenza, vaccines, and vaccination. Similar studies should be undertaken on a larger scale to fully interrogate the differences between pharmacy staff groups.

Beyond fragmentary: A proposed measure for travel vaccination concerns

The travel medicine literature points to travelers' concerns as significant promoters of their under-vaccinations. Therefore, this study researches the hitherto understudied concept of vaccination concern and its theoretical scope in the international travel space. It attempts a conceptualization of the concept by delimiting its theoretical scope and proposes a measure for it. An exploratory sequential mixed-methods design was used to conduct four interlocking studies using data from a netnography, field interviews, and surveys among varied international travelers. A scale with six dimensions, comprising safety, efficacy, cost, time, access, and autonomy concerns were revealed. The scale significantly explained mainstream and segments-based tourists' uptake attitudes and behavior for their eligible vaccines. The findings suggest that anti-travel vax sentiments and public vax sentiments despite conceptually similar are considerably distinct. The broad nature of the scale and its prediction of travelers' vaccine uptake make it clinically relevant for tracking and resolving concerns for increased vaccine uptake.

[The vaccine-condition or vaccination passport and its eventual fit into a broad recommended vaccination framework against COVID-19]

Es importante parar mientes en la eventual aplicación del certificado de vacunación contra la COVID-19 como condición para el ejercicio de actividades y reflexionar de manera anticipada acerca de los problemas que en términos jurídicos puede plantear el empleo de esta técnica. A tal efecto, hay que comenzar por significar los presupuestos que serían necesarios para justificar su activación, incluyendo el consenso científico sobre el alcance de la inmunidad concedida por las vacunas COVID-19, señaladamente en su faceta colectiva de bloqueo de la transmisión. Asimismo, se hace hincapié en la importancia de ampliar las miras en el sentido de interiorizar que el pasaporte o pase de vacunación constituye solo una de las muchas opciones dentro de un rico catálogo de posibilidades a la hora de reforzar, mediante incentivos, el modelo de vacunación recomendada y adoptado en la Estrategia de vacunación contra la COVID-19, contando entre ellas con la utilización del nudging. En todo caso, de instalarse y expandirse al cabo una condicionalidad en grado de influir significativamente en lo cotidiano, podría desembocarse en una suerte de obligatoriedad indirecta, con el riesgo de disfunciones en términos de igualdad y coherencia sistémica si los poderes públicos no contribuyen a perfilar con claridad antes los límites legales y a encauzar un proceso que de suyo podría ser disperso y desordenado.

Mandatory vaccination for seasonal influenza: what are nurses' views?

BACKGROUND

Preventing seasonal influenza is a public health priority but, although the benefits of vaccinating healthcare workers (HCWs) are emphasised, seasonal influenza vaccine uptake rates remain low. Voluntary vaccination policies have been less successful in achieving high vaccine uptake when compared to mandatory policies and the persistently low vaccine uptake among HCWs has fuelled debate on whether mandatory vaccination programmes should be implemented in the interest of patient safety.

AIM

This study explored nurses' views on mandatory vaccination policy for seasonal influenza.

METHODS

A self-selected sample (n=35) of qualified nurses working in two large hospital sites in Ireland participated in five focus groups. Data were analysed using Braun and Clarke's framework.

FINDINGS

Two themes were identified: (1) mixed views on mandatory vaccination and (2) leave nurses to make their own choice on vaccination.

CONCLUSION

This study provides an understanding of nurses' views regarding mandatory vaccination policy for seasonal influenza and highlights that individual choice and autonomy are crucial for vaccine acceptance.

Promoting Influenza Vaccination among Staff of Nursing Homes According to Behavioral Insights: Analyzing the Choice Architecture during a Nudge-Based Intervention

(1) Background: Influenza vaccination uptake in nursing home (NH) workers is uncommon. The aim of this study was to understand the choice architecture of influenza vaccination acceptance or refusal among them and to promote vaccination acceptance using the nudge approach. (2) Methods: In autumn 2019, a nudge intervention with a contextual qualitative analysis of choice architecture of vaccination was performed among the staff of eight Tuscan NHs. In summer 2020, a cross-sectional study including the staff of 111 NHs (8 in the nudge, 103 in the comparison group) was conducted to assess the impact of the nudge intervention in promoting vaccination uptake. (3) Results: Macro-categories of motivations for vaccination uptake that emerged from the qualitative analysis were risk perception, value dimension, and trust, while those regarding refusal were risk perception, distrust, value dimension, and reasons related to one’s health. Considering the cross-sectional study, influenza vaccination uptake in the 2018–2019 season was similar in the two groups (23.6% vs. 22.2% respectively, in the nudge and comparison group), but significantly different in the 2019–2020 season: 28% in the nudge vs. 20% in the comparison group. Also, the intention to get the vaccine in the 2020–2021 season was significantly different in the two groups: 37.9% in the nudge and 30.8% in the comparison group. (4) Conclusions: Nudge interventions-simple, fast, low cost-could be effective in promoting vaccination acceptance among NH workers and the analysis of choice architecture could be useful in improving tailored, new nudge interventions aimed at modifying irrational biased and cognitive errors.

The continuum of influenza vaccine hesitancy among nursing professionals in Hong Kong

INTRODUCTION

Influenza vaccine hesitancy among healthcare workers poses challenges to the achievement of herd immunity and causes infection risks to vulnerable patients. This study aimed to quantify the extent of influenza vaccine hesitancy among nurses in Hong Kong, to delineate its pattern, and to explore its socio-demographic, professional and personal correlates.

METHOD

Nurses in Hong Kong were recruited in a cross-sectional study involving the administration of an online questionnaire survey after the 2017/18 winter influenza season. Respondents' influenza vaccination behaviours, attitudes and psychological antecedents were assessed, followed by their delineation into subgroups along the hesitancy continuum through a combination of multiple correspondence analysis and K-means cluster analysis. Socio-demographic, professional and personal correlations of subgrouping were investigated using generalised ordered logistic regression.

RESULTS

The overall vaccination coverage of nurses for the 2017/18 influenza season was 44%. Five clusters were differentiated by the level of influenza vaccine hesitancy: "Very high hesitancy-to-complete refusal" (n = 56; 7%) characterised by outright refusal of vaccination; "High hesitancy" (n = 171; 23%) distinguished by tendency of skipping vaccination and scepticism about safety of vaccine; "Moderate hesitancy" (n = 273; 36%) with uncertainties towards vaccination, mistrust of the government's vaccine recommendations and priority concern on affordability of vaccine; "Low hesitancy" (n = 95; 13%) with cautious acceptance towards vaccination and "No-to-minimal hesitancy" (n = 158; 21%) with strong vaccine confidence and compliance greatly linked to convenience of vaccine access. Nurses having completed at least 3 years' pre-registration professional training, having most family members vaccinated against influenza, and with influenza vaccination history during studentship were less vaccine hesitant.

CONCLUSION

With more than half of the nurses in Hong Kong having moderate or higher level of influenza vaccine hesitancy, interventions customised to the needs of nurses as reflected from the characteristics of clusters along the vaccine hesitancy continuum could form an important strategy for improving vaccination uptake.

Vaccinating for Whom? Distinguishing between Self-Protective, Paternalistic, Altruistic and Indirect Vaccination

Preventive vaccination can protect not just vaccinated individuals, but also others, which is often a central point in discussions about vaccination. To date, there has been no systematic study of self- and other-directed motives behind vaccination. This article has two major goals: first, to examine and distinguish between self- and other-directed motives behind vaccination, especially with regard to vaccinating for the sake of third parties, and second, to explore some ways in which this approach can help to clarify and guide vaccination debates and policy. I propose conceiving of vaccination in terms of three basic elements: the vaccination decision-maker, the vaccine recipient and the primary beneficiary. I develop a taxonomy based on the relations between these elements to distinguish four kinds of vaccination: self-protective, paternalistic, altruistic and indirect. I finally discuss the case of human papillomavirus vaccine regulation for men and women to show how each kind of vaccination is associated with and raises specific ethical questions.

Cognitive Bias in Clinicians' Communication about Human Papillomavirus Vaccination

National guidelines recommend human papillomavirus (HPV) vaccination for all 11-12-year-olds, but uptake among United States adolescents remains low. A major barrier to greater uptake is the lack of effective recommendations for HPV vaccine from clinicians. One potential influence on clinicians' recommendations for HPV vaccine that has been relatively unexplored is that of cognitive biases, or errors in judgement that result from 'mental shortcuts' used to make decisions under uncertainty. Therefore, we analyzed qualitative data from interviews with 32 pediatric clinicians using a framework of nine cognitive biases relevant to HPV vaccination: omission bias, ambiguity aversion, present bias, availability bias, optimism bias, naturalness bias, protected values, anchoring bias, and confirmation bias. We used a directed content analysis approach to iteratively code and analyze all transcripts in the dataset. We found evidence for several cognitive biases that were related to weaker recommendations for HPV vaccine. Commonly identified biases included anchoring bias (perception that vaccination unnecessary due to age/pubertal status); present bias (perception of burdens related to discussing vaccination), and optimism bias (belief that patient at low risk for HPV acquisition). We found less frequent evidence for ambiguity aversion (perception of missing information regarding vaccination) and omission bias (deferring vaccination). Other biases were identified infrequently or not at all. Our findings suggest that several cognitive biases may be an influence on clinicians' communication about HPV vaccine. Raising awareness of cognitive biases related to making HPV vaccine recommendations could help to strengthen the recommendations that clinicians provide.

To Be or Not to Be Vaccinated? The Ethical Aspects of Influenza Vaccination among Healthcare Workers

Influenza is a highly contagious airborne disease with a significant morbidity and mortality burden. Seasonal influenza (SI) vaccination has been recommended for healthcare workers (HCWs) for many years. Despite many efforts to encourage HCWs to be immunized against influenza, vaccination uptake remains suboptimal. Sometimes there is a significant sign of improvement, only if numerous measures are taken. Is 'the evidence' and 'rationale' sufficient enough to support mandatory influenza vaccination policies? Most voluntary policies to increase vaccination rates among HCWs have not been very effective. How to close the gap between desired and current vaccination rates? Whether (semi)mandatory policies are justified is an ethical issue. By means of a MEDLINE search, we synthesized the most relevant publications to try to answer these questions. Neither the 'clinical' Hippocratic ethics (the Georgetown Mantra: autonomy, beneficence, non-maleficence, and justice), nor the 'public health' ethics frameworks resolve the question completely. Therefore, recently the 'components of justice' framework was added to the ethical debate. Most options to increase the uptake arouse little ethical controversy, except mandatory policies. The success of vaccination will largely depend upon the way the ethical challenges like professional duty and ethics (deontology), self-determination, vaccine hesitance, and refusal ('conscientious objector') are dealt with.

Mandatory policies for influenza vaccination: Views of managers and healthcare workers in England

INTRODUCTION

Mandatory policies have the potential to increase uptake of influenza ('flu') vaccination among healthcare workers (HCWs), but concerns have been expressed about their acceptability and effectiveness. We explored views on three mandatory policies (declination forms, face masks or reduced patient contact, and mandatory vaccination) among both HCWs and flu vaccination programme managers in the National Health Service (NHS) in England.

METHOD

A mixed method approach was employed. An online cross-sectional survey was conducted with staff responsible for implementing influenza campaigns in NHS trusts (healthcare organisations) in England (n = 72 trusts). The survey measured perceived effectiveness of the three mandatory policies and perceived support for them among HCWs. Qualitative interviews were conducted in four trusts, with influenza campaign managers (n = 24) and with HCWs who had the opportunity to receive the influenza vaccination (n = 32). Interviews explored respondents' views of the three strategies and were analysed thematically using QSR NVivo 11 All data were collected shortly after the 2016/2017 influenza season.

RESULTS

In the survey, views varied on the effectiveness of the three policies and none of the interventions were thought to be strongly supported by HCWs, with particularly low levels of support perceived for mandatory vaccination and for face masks or reduced patient contact. The qualitative interviews revealed substantial concerns around the practicability and enforceability of mandatory policies and the potential discriminatory effect on HCWs who made a principled decision or had medical reasons for exemption. Additional doubts were also expressed regarding the effectiveness of face masks and their potential to worry patients, and the ethics of compelling staff to accept medical intervention.

DISCUSSION

Mandatory vaccination and face masks would not be strongly supported if introduced in the UK. If declination forms are adopted, they should be used in a constructive intelligence-gathering manner which avoids stigmatising HCWs.

Applying lessons from behavioral economics to increase flu vaccination rates

Seasonal influenza imposes an enormous burden on society every year, yet many people refuse to obtain flu shots due to misconceptions of the flu vaccine. We argue that recent research in psychology and behavioral economics may provide the answers to why people hold mistaken beliefs about flu shots, how we can correct these misconceptions, and what policy-makers can do to increase flu vaccination rates.

Changes in Influenza Vaccination Requirements for Health Care Personnel in US Hospitals

IMPORTANCE

Annual influenza vaccinations are currently recommended for all health care personnel (HCP) to limit the spread of influenza to those at high risk of developing serious complications from the virus. Vaccination coverage has been shown to be significantly greater among employers requiring and encouraging HCP to receive the annual influenza vaccination.

OBJECTIVES

To compare the proportion of respondent hospitals requiring HCP to receive annual influenza vaccination between 2013 and 2017 and to assess the degree to which these proportions differed between Veterans Affairs (VA) and non-VA hospitals.

DESIGN, SETTING, AND PARTICIPANTS

This national survey study included responses from 1062 infection preventionists between 2013 and 2017 from nationally representative samples of all VA and non-VA hospitals in the United States. Data analysis was conducted from November 17, 2017, to March 26, 2018.

MAIN OUTCOMES AND MEASURES

Survey response indicating hospital requirement for annual influenza vaccination of HCP.

RESULTS

The overall response rate for the 2013 survey was 69.3% (non-VA, 70.6% [403 of 571]; VA, 63.5% [80 of 126]) and in 2017 was 59.1% (non-VA, 59.1% [530 of 897]; VA, 58.9% [73 of 124]). Among all responding hospitals, mandatory influenza vaccination requirements for HCP increased from 37.1% in 2013 to 61.4% in 2017 (difference, 24.3%; 95% CI, 18.4%-30.2%; P < .001). This change was driven by non-VA hospitals, as requirement policies increased from 44.3% (171 of 386) in 2013 to 69.4% (365 of 526) in 2017 (difference, 25.1%; 95% CI, 18.8%-31.4%; P < .001). Conversely, there was no significant change during this period in the proportion of VA hospitals that required influenza vaccinations for HCP (1.3% [1 of 77] to 4.1% [3 of 73]; difference, 2.8%; 95% CI, -2.4% to 8.0%; P = .29).

CONCLUSIONS AND RELEVANCE

Despite a substantial increase in mandates among non-VA hospitals, we found that many non-VA hospitals and nearly all VA hospitals are still not currently mandating influenza vaccinations for HCP. In addition to implementing other well-described strategies to increase vaccination rates, health care organizations should consider mandating influenza vaccinations while appropriately weighing and managing the moral, ethical, and legal implications.

Addressing barriers to vaccine acceptance: an overview

Addressing the drivers of vaccine hesitancy and the barriers to vaccine acceptance is a complex but important task. While the percentage of hesitant does vary from country to country and in time few, if any, countries are ever free from this problem. Overcoming hesitancy requires detection, diagnosis and tailored intervention as there is no simple strategy that can address all of the barriers to vaccine acceptance. Immunization program managers and health care workers need to become adept at recognizing and tackling hesitancy in all of its incarnations if high levels of vaccine acceptance are to be achieved but must also actively support immunization acceptors in order to build and support vaccine acceptance resiliency. This paper presents evidence-informed strategies to achieve these goals.