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Kömürlüoğlu A, Akaydın Gültürk E, Yalçın SS. Turkish Adaptation, Reliability, and Validity Study of the Vaccine Acceptance Instrument. Vaccines (Basel) 2024; 12:480. [PMID: 38793731 PMCID: PMC11125573 DOI: 10.3390/vaccines12050480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
This research study aimed to assess the reliability and validity of the Turkish version of the Vaccine Acceptance Instrument (VAI). The VAI is a 20-item Likert-type scale, with responses ranging across seven points. A systematic approach was followed to translate the scale into Turkish, involving translation, expert panel evaluation, back-translation, and pilot testing. The Vaccine Acceptance Instrument and a sociodemographic data form were used for data collection. The reliability of the scale was tested by test-retest analysis, and its internal reliability was examined by Cronbach's alpha test. The factor structure was examined using Exploratory Factor Analysis (EFA). Confirmatory Factor Analysis (CFA) was employed to assess the scale's fit. Overall, 229 participants were included in the study. In test-retest reliability analysis, the intraclass correlation coefficient of the scale was 0.992 (95% CI: 0.987-0.996). The Cronbach's alpha value of the scale was 0.824. A four-factor structure was determined. The model had an acceptable fit [χ2/df = 380.04/164 (2,317) p < 0.001, CFI = 0.91, GFI = 0.90, AGFI = 0.906, NFI = 0.90, RMSEA = 0.076]. The mean total VAI score was 112.71 ± 17.02. The low education level of the mother, being a housewife, and parents not having the COVID-19 vaccine were statistically significantly associated with a low scale score and low vaccine acceptance (p < 0.05). The Turkish adaptation of the VAI demonstrated satisfactory levels of validity and reliability following rigorous testing.
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Affiliation(s)
- Ayça Kömürlüoğlu
- Department of Pediatrics, Faculty of Medicine, Sivas Cumhuriyet University, Sivas 58140, Türkiye
| | - Esra Akaydın Gültürk
- Department of Biostatistics, Faculty of Medicine, Sivas Cumhuriyet University, Sivas 58140, Türkiye;
| | - Sıddika Songül Yalçın
- Division of Social Pediatrics, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara 06430, Türkiye;
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Jammeh A, Muhoozi M, Kulane A, Kajungu D. Comparing full immunisation status of children (0-23 months) between slums of Kampala City and the rural setting of Iganga District in Uganda: a cross-sectional study. BMC Health Serv Res 2023; 23:856. [PMID: 37580708 PMCID: PMC10424339 DOI: 10.1186/s12913-023-09875-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 08/04/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Immunisation remains the most cost-effective public health intervention in preventing morbidity and mortality due to Vaccine-Preventable Diseases (VPDs). The study aims to compare the differences in immunisation coverage amongst children aged 0 to 23 months living in slums of Kampala city and Iganga as rural districts in Uganda. METHODS This study utilises data from a cross-sectional survey done in 2019 in the slums of Kampala City and the rural district of Iganga within the Health and Demographic Surveillance Site (HDSS). It included 1016 children aged 0-23 months and their parents. A logistic regression model was used to analyse the relationship between multiple independent variables and the binary dependent variables (fully immunised) using Stata statistical software. The measures of association were odds ratios reported with a corresponding 95% confidence interval. RESULTS Out of the 1016 participants, 544 participants live in the rural area and 472 participants in the slums. Slums had 48.9% (n = 231) of fully immunised children whilst rural areas had 43.20% (n = 235). The multivariate analysis showed that children living in slums are more likely to be fully immunised as compared to their counterparts in rural areas (Odds ratio:1.456; p = 0.033; CI:1.030-2.058). Immunisation coverage for BCG (98.9%), Polio 0 (88.2%), Penta1 (92.7%), and Pneumo1 (89.8%) were high in both settlements. However, the dropout rate for subsequent vaccines was high 17%, 20% and 41% for Penta, pneumococcal and rota vaccines respectively. There was poor uptake of the new vaccines with slums having 73.4% and 47.9% coverage for pneumococcal and rota vaccines respectively and rural areas had 72.1% and 7.5% for pneumococcal and rota vaccines respectively. CONCLUSION The low full immunisation status in this study was attributed to the child's residence and the occupation of the parents. Lack of education and poor access to messages on immunisation (inadequate access to mass media) are other contributing factors. Educational messages on the importance of immunisation targeting these underserved populations will improve full immunisation coverage.
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Affiliation(s)
- Awa Jammeh
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
- Edward Francis Small Teaching Hospital, Banjul, The Gambia.
| | - Michael Muhoozi
- Center for Health and Population Research, Makerere University, Kampala, Uganda
| | - Asli Kulane
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Dan Kajungu
- Center for Health and Population Research, Makerere University, Kampala, Uganda
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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Jacques M, Lorton F, Dufourg MN, Bois C, Launay E, Siméon T, Raude J, Guen CGL, Lévy-Brühl D, Charles MA, Chalumeau M, Scherdel P. Determinants of incomplete vaccination in children at age two in France: results from the nationwide ELFE birth cohort. Eur J Pediatr 2023; 182:1019-1028. [PMID: 36542162 PMCID: PMC9768772 DOI: 10.1007/s00431-022-04733-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/18/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022]
Abstract
Incomplete vaccination in the pediatric population is a growing public health issue in high-income countries, but its determinants are poorly understood. Their identification is necessary to design target actions that can improve vaccination uptake. Our aim was to assess the determinants of incomplete vaccination in two-year-old children in France. Among the 18,329 children included in the 2011 ELFE French nationwide population-based birth cohort, we selected those for whom vaccination status was available at age two years. Incomplete vaccination was defined as ≥ 1 missing dose of recommended vaccines. Potential determinants of incomplete vaccination were identified by using logistic regression, taking into account attrition and missing data. Of the 5,740 (31.3%) children analyzed, 46.5% (95% confidence interval [CI] 44.7-48.0) were incompletely vaccinated. Factors independently associated with incomplete vaccination were having older siblings (adjusted odds ratio 1.18, 95% CI [1.03-1.34] and 1.28 [1.06-1.54] for one and ≥ 2 siblings, respectively, vs. 0), residing in an isolated area (1.92 [1.36-2.75] vs. an urban area), parents not following health recommendations or using alternative medicines (1.81 [1.41-2.34] and 1.23 [1.04-1.46], respectively, vs. parents confident in institutions and following heath recommendations), not being visited by a maternal and child protection service nurse during the child's first two months (1.19 [1.03-1.38] vs. ≥ 1 visit), and being followed by a general practitioner (2.87 [2.52-3.26] vs. a pediatrician). CONCLUSIONS Incomplete vaccination was highly prevalent in the studied pediatric population and was associated with several socio-demographic, parental, and healthcare service characteristics. These findings may help in designing targeted corrective actions. WHAT IS KNOWN • Incomplete vaccination in the pediatric population is a growing public health issue in high-income countries. • The partial understanding of the determinants of incomplete vaccination precludes the design of effective targeted corrective actions. WHAT IS NEW • High prevalence of incomplete vaccination at age two years in France. • Incomplete vaccination was independently associated with several socio-demographic, parental, and healthcare service characteristics.
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Affiliation(s)
- Marianne Jacques
- Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Université Paris Cité, Inserm, Center for Research in Epidemiology and StatisticS (CRESS), 75004 Paris, France
- grid.277151.70000 0004 0472 0371Inserm 1413 CIC FEA, Nantes University Hospital, Nantes, France
| | - Fleur Lorton
- Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Université Paris Cité, Inserm, Center for Research in Epidemiology and StatisticS (CRESS), 75004 Paris, France
- grid.277151.70000 0004 0472 0371Inserm 1413 CIC FEA, Nantes University Hospital, Nantes, France
- grid.277151.70000 0004 0472 0371Department of Pediatric Emergency Care, Nantes University Hospital, Nantes, France
| | - Marie-Noëlle Dufourg
- grid.7429.80000000121866389French Institute for Demographic Studies (Ined), Inserm, French Blood Agency, ELFE Joint Unit, Aubervilliers, France
| | - Corinne Bois
- grid.7429.80000000121866389French Institute for Demographic Studies (Ined), Inserm, French Blood Agency, ELFE Joint Unit, Aubervilliers, France
| | - Elise Launay
- Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Université Paris Cité, Inserm, Center for Research in Epidemiology and StatisticS (CRESS), 75004 Paris, France
- grid.277151.70000 0004 0472 0371Inserm 1413 CIC FEA, Nantes University Hospital, Nantes, France
- grid.277151.70000 0004 0472 0371Department of Pediatric Emergency Care, Nantes University Hospital, Nantes, France
| | - Thierry Siméon
- grid.7429.80000000121866389French Institute for Demographic Studies (Ined), Inserm, French Blood Agency, ELFE Joint Unit, Aubervilliers, France
| | - Jocelyn Raude
- grid.414412.60000 0001 1943 5037EHESP-School of Public Health, Rennes, France
| | - Christèle Gras-Le Guen
- Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Université Paris Cité, Inserm, Center for Research in Epidemiology and StatisticS (CRESS), 75004 Paris, France
- grid.277151.70000 0004 0472 0371Inserm 1413 CIC FEA, Nantes University Hospital, Nantes, France
- grid.277151.70000 0004 0472 0371Department of Pediatric Emergency Care, Nantes University Hospital, Nantes, France
| | - Daniel Lévy-Brühl
- grid.493975.50000 0004 5948 8741Santé Publique France, French National Public Health Agency, Saint-Maurice, France
| | - Marie-Aline Charles
- grid.7429.80000000121866389French Institute for Demographic Studies (Ined), Inserm, French Blood Agency, ELFE Joint Unit, Aubervilliers, France
| | - Martin Chalumeau
- Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Université Paris Cité, Inserm, Center for Research in Epidemiology and StatisticS (CRESS), 75004 Paris, France
- grid.508487.60000 0004 7885 7602Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants malades hospital, Université Paris Cité, Paris, France
| | - Pauline Scherdel
- Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Université Paris Cité, Inserm, Center for Research in Epidemiology and StatisticS (CRESS), 75004 Paris, France
- grid.277151.70000 0004 0472 0371Inserm 1413 CIC FEA, Nantes University Hospital, Nantes, France
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Regazzi L, Marziali E, Lontano A, Villani L, Paladini A, Calabrò GE, Laurenti P, Ricciardi W, Cadeddu C. Knowledge, attitudes, and behaviors toward COVID-19 vaccination in a sample of Italian healthcare workers. Hum Vaccin Immunother 2022; 18:2116206. [PMID: 36197125 PMCID: PMC9746397 DOI: 10.1080/21645515.2022.2116206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/29/2022] [Accepted: 08/10/2022] [Indexed: 12/15/2022] Open
Abstract
Vaccine hesitancy in healthcare workers (HCWs) has been studied for various contagious diseases, but there is still insufficient knowledge about this phenomenon for COVID-19. We developed and validated a knowledge, attitude, and practice survey of 39 questions to assess Italian HCWs' hesitancy toward vaccination in general (general hesitancy), COVID-19 vaccination (COVID-19 hesitancy), and public health injunctive measures (refusal of obligations). The survey was administered through a web platform between July and November 2021. Three multivariable logistic regressions were performed to evaluate the association between the explored dimensions of hesitancy and the potential determinants investigated. Out of 2,132 respondents with complete answers, 17.0% showed to be generally hesitancy toward vaccination, 32.3% were hesitant on COVID-19 vaccination, while 18.8% were categorized as refusing obligations. A significant protective effect against all three dimensions of hesitancy was found for increasing fear of COVID-19, advising COVID-19 vaccination to relatives and patients, having received flu vaccination in the previous year and having higher levels of education. Better self-rated knowledge about COVID-19 vaccines and reading up institutional sources were significantly protective against general and COVID-19 hesitancy, while being a physician rather than another healthcare professional was protective only against COVID-19 hesitancy. Conversely, increasing age and referring to colleagues to expand knowledge about COVID-19 were positively associated with COVID-19 hesitancy. The determinants of general hesitancy, COVID-19 hesitancy and the refusal of obligations are mostly overlapping. Given the great influence they exert on patients and communities, it is pivotal to limit HCWs vaccine hesitancy through appropriate training activities.
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Affiliation(s)
- Luca Regazzi
- Section of Hygiene, University Department of Life Sciences and Public Health — Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eleonora Marziali
- Section of Hygiene, University Department of Life Sciences and Public Health — Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alberto Lontano
- Section of Hygiene, University Department of Life Sciences and Public Health — Università Cattolica del Sacro Cuore, Rome, Italy
| | - Leonardo Villani
- Section of Hygiene, University Department of Life Sciences and Public Health — Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Paladini
- Section of Hygiene, University Department of Life Sciences and Public Health — Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanna Elisa Calabrò
- Section of Hygiene, University Department of Life Sciences and Public Health — Università Cattolica del Sacro Cuore, Rome, Italy
| | - Patrizia Laurenti
- Section of Hygiene, University Department of Life Sciences and Public Health — Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Women, Children and Public Health — Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Walter Ricciardi
- Section of Hygiene, University Department of Life Sciences and Public Health — Università Cattolica del Sacro Cuore, Rome, Italy
| | - Chiara Cadeddu
- Section of Hygiene, University Department of Life Sciences and Public Health — Università Cattolica del Sacro Cuore, Rome, Italy
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Waser M, Heiss R, Borena W. Factors affecting children's HPV vaccination in Austria: Evidence from a parent survey. Hum Vaccin Immunother 2022; 18:2126251. [PMID: 36251011 DOI: 10.1080/21645515.2022.2126251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Human papillomavirus (HPV) is a sexually transmitted infection that causes cervical cancer, head and neck cancer, other urogenital cancers, and genital warts. In Austria, where HPV vaccination is free for children, the vaccination rate nevertheless remains insufficient for herd immunity against HPV. Using a cross-sectional survey of parents (N = 334) in the state of Tyrol, Austria, we examined parents' reasons for rejecting children's HPV vaccination and key predictors of vaccination intention for their children, including knowledge about HPV, attitude toward vaccination, sources of information about the HPV vaccine, socioeconomic factors, and HPV vaccination intention. Data analyzed using descriptive statistics and logistic regression modeling revealed an overall 81.9% acceptance rate of HPV vaccination. The most common reasons for vaccine hesitancy were a fear of side effects, a perceived lack of information, and the perception that children are too young to be vaccinated. A high level of knowledge about HPV was significantly associated with vaccine acceptance for female but not male children. Negative attitude toward vaccination was significantly related to lower vaccine acceptance, and parents who reported informing themselves about HPV vaccination from online sources were less likely to accept vaccination. Such results call for more educational measures to reduce misinformation about HPV vaccination and thereby reduce the fear of its side effects and promote early vaccination. More information is also needed to improve parents' attitude toward and their knowledge about vaccination, the dissemination of which should focus on the benefits of vaccines for children of both sexes.
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Affiliation(s)
- Madeleine Waser
- Center for Social & Health Innovation MCI Management Center Innsbruck, Innsbruck, Austria
| | - Raffael Heiss
- Center for Social & Health Innovation MCI Management Center Innsbruck, Innsbruck, Austria
| | - Wegene Borena
- Institute of Virology, Innsbruck Medical University, Innsbruck, Austria
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Chen S, Yue W, Han X, Luo J, Na L, Yang M. An integrative review on the maternal health literacy among maternal and child workers. J Nurs Manag 2022; 30:4533-4548. [PMID: 36190727 DOI: 10.1111/jonm.13830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 12/30/2022]
Abstract
AIMS This study aim to capture the most comprehensive evidence-based dimensions of maternal health literacy, including summarizing the definitions, theoretical frameworks, measuring instruments, and the association between maternal health literacy and health behaviours. BACKGROUND Maternal health literacy has been recognized as an important approach to achieving high-quality maternal and child health; however, little is known about maternal health literacy comprehensively and scientifically. EVALUATION An integrative review retrieved articles from 11 databases, following the methodology of Whittemore and Knafl. Inductive content analysis and narrative synthesis were conducted, guided by the aim of this review. KEY ISSUES A total of 5580 articles were retrieved and 23 articles were finally identified. Existing definitions and theoretical frameworks took less consideration of maternal applicability and failed to summarize maternal health literacy from a dynamic and systematic perspective. Measurement instruments were set up with many items that make it difficult to quickly screen for poor maternal health literacy. Most articles proved the association between maternal health literacy and health behaviours through correlation analysis or regression analysis but less explored the influence pathways between them. CONCLUSION The definition and theoretical framework need to focus on maternal applicability and explain the process of individual mothers acquiring and understanding health knowledge and skills from a dynamic and systematic perspective. A rapid instrument for maternal health literacy should be developed and high-quality empirical research was conducted to understand the associated mechanisms between maternal health literacy and health behaviours. IMPLICATIONS FOR NURSING MANAGEMENT It is necessary to strengthen maternal and child health education of primary health care nurses and enhance their ability to help perinatal women use maternal and child health information effectively.
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Affiliation(s)
- Shanxia Chen
- School of Nursing, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wei Yue
- Affiliated Foshan Maternal and Child Healthcare Hospital, Southern Medical University, Foshan, China
| | - Xinrui Han
- School of Nursing, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jianghe Luo
- Department of Gynecology and Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Liu Na
- School of Nursing, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ming Yang
- School of Nursing, Guangzhou University of Chinese Medicine, Guangzhou, China
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Shared understandings of vaccine hesitancy: How perceived risk and trust in vaccination frame individuals' vaccine acceptance. PLoS One 2022; 17:e0276519. [PMID: 36269739 PMCID: PMC9586382 DOI: 10.1371/journal.pone.0276519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
Extensive research has framed vaccine hesitancy as a property of a heterogeneous group of individuals, ranging from total acceptance to complete refusal. Nevertheless, not much research has explored this heterogeneity, mainly focusing on central tendencies of single belief-related items. Using data from an original survey on a sample of Italian citizens, this paper examines this heterogeneity, exploiting individuals’ cognitive variation to map clusters of individuals who share similar cognitive schemas on vaccine uptake. The results showed the existence three groups, characterized by a different articulation of predictors of vaccine hesitancy, revealing different understandings of vaccine uptake. We then analyzed within-cluster characteristics and showed that cognitive segmentation was connected to different levels of perceived risk, confidence, and support for vaccination. We further showed that cognitive clustering also entailed a mean of social stratification that was correlated with individuals’ educational levels, and that the predictors of vaccine hesitancy were articulated differently in each group. This study, adopting a recent perspective in the analysis of systems of beliefs, moves one step further in disentangling the complexity of vaccine acceptance. Results suggested the usefulness of including individuals’ cognitive characteristics in vaccine hesitancy research and in the development of interventions addressed at increasing vaccine acceptance.
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Firouzbakht M, Sharif Nia H, Kazeminavaei F, Rashidian P. Hesitancy about COVID-19 vaccination among pregnant women: a cross-sectional study based on the health belief model. BMC Pregnancy Childbirth 2022; 22:611. [PMID: 35918665 PMCID: PMC9344440 DOI: 10.1186/s12884-022-04941-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pregnant women are at high risk for affliction by coronavirus disease 2019 (COVID-19). Vaccination is a main strategy to prevent and manage the COVID-19 pandemic. However, hesitancy about COVID-19 vaccination (HACV) is a major public health threat and a major barrier to herd immunity. The aim of the study was to evaluate pregnant women's HACV based on the Health Belief Model (HBM). METHODS This cross-sectional study was conducted in 2021-2022. Participants were 352 pregnant women selected from several healthcare centers in the north of Iran. Instruments for data collection were a demographic questionnaire, a COVID-19 Knowledge Questionnaire, a COVID-19 Health Belief Questionnaire, and a question about HACV. Logistic regression analysis was used to assess the effects of the study variables on HACV. RESULTS The rate of HACV was 42.61%. In the regression model, the three factors of perceived benefits (aOR: 0.700; 95% CI: 0.594 to 0.825), cues to action (aOR: 0.621; 95% CI: 0.516 to 0.574), and history of reproductive problems (aOR: 2.327; 95% CI: 0.1.262 to 4.292) had significant effects on HACV (P < 0.001). CONCLUSION HACV is highly prevalent among pregnant women. The perceived benefits and cues to action components of HBM have significant effects on pregnant women's HACV, while the perceived threat component has no significant effect on it. HBM is a good model to explain HACV among pregnant women. Educational interventions are necessary to improve pregnant women's awareness of the risks of COVID-19 for them and their fetus.
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Affiliation(s)
- Mojgan Firouzbakht
- Department of Nursing- Midwifery, Comprehensive Health Research Center, Babol Branch, Islamic Azad University, Babol, Iran.
| | - Hamid Sharif Nia
- Amol Faculty of Nursing and Midwifery, Traditional and Complementary Medicine Research Center, Addiction Institute, Mazandaran University of Medical Science, Sari, Iran
| | - Fatemeh Kazeminavaei
- Department of Nursing- Midwifery, Comprehensive Health Research Center, Babol Branch, Islamic Azad University, Babol, Iran
| | - Pegah Rashidian
- Student Research committee, Guilan University of Medical Sciences, Rasht, Iran
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Martinelli M, Veltri GA. Do cognitive styles affect vaccine hesitancy? A dual-process cognitive framework for vaccine hesitancy and the role of risk perceptions. Soc Sci Med 2021; 289:114403. [PMID: 34547544 DOI: 10.1016/j.socscimed.2021.114403] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 08/24/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
RATIONALE In this study, we consider cognitive differences in vaccine hesitancy and how perceived risks intervene in this relationship. Recent research agrees on the existence of two cognitive processes, intuitive and analytic cognition. Different individuals lean toward one of these processes with varying degrees of strength, influencing day-to-day behavior, perceptions, and decisions. Thinking dispositions might influence, at the same time, vaccine acceptance and perceived risks of vaccine-preventable disease, but the implications of individuals' cognitive differences for vaccination uptake have seldom been addressed from a sociological standpoint. OBJECTIVE We bridge this gap by adopting a dual-process framework of cognition and investigate how thinking styles have a direct association with vaccine hesitancy and an indirect one through perceptions of risk. METHODS We use data from original surveys carried out between September and November 2019 on a sample of the Italian population, participating in an online panel run by a major Italian survey company. We use Karlson, Holm, and Breen (KHB) decomposition to compare coefficients of nested-nonlinear models, separate the direct and indirect association of cognitive processes with vaccine hesitancy, and disentangle the contribution of each measure of risk perception. RESULTS Net of individual socio-demographic characteristics, intuitive thinking is positively associated with the likelihood of being vaccine hesitant, and this direct association is as important as the indirect one through risk perceptions. Affective risk perceptions account for over half of the indirect association, underlining the centrality of affective versus probabilistic approaches to risk perception. CONCLUSION This study contributes to the existing literature by highlighting the importance of including cognitive characteristics in vaccine hesitancy research, and empirically showing individuals' qualitatively complex perceptions of risks. Taking into account individuals' preferred cognitive style and affective concerns might be important in developing better tailored communication strategies to contain vaccine hesitancy.
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Affiliation(s)
- Mauro Martinelli
- Department of Sociology and Social Research, University of Trento, Trento, Italy.
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Spadea T, Fano V, Piovesan C, Rusciani R, Salamina G, Greco G, Colaiocco G, Ramigni M, Declich S, Petrelli A, Pezzotti P, Fabiani M. Early childhood vaccination coverage and timeliness by macro-area of origin in children born to foreign women residing in Italy. Public Health 2021; 196:138-145. [PMID: 34214751 DOI: 10.1016/j.puhe.2021.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/03/2021] [Accepted: 05/21/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Country of origin might affect vaccine uptake in children born to immigrants. We aimed to evaluate differences in childhood vaccination coverage (VC) and timeliness by macro-area of origin of foreign mothers residing in Italy. STUDY DESIGN Multicentre retrospective birth cohorts. METHODS We analysed data of 23,287 children born in 2009-2014 to foreign women in the cities of Rome, Turin and Treviso. We retrieved data through record-linkage of the population, vaccination and birth registries. We estimated VCs at different ages for vaccines against tetanus, measles and meningococcal group-C, using the Kaplan-Meier method. Factors associated with vaccine uptake were evaluated using multilevel Poisson models. RESULTS Estimates of VC at any age and for all antigens were significantly lower in children born to women from Asia and higher in children born to women from Africa, as compared to other macro-areas. Similar differences by area of origin were observed for timeliness; independently of mother's sociodemographic characteristics and neonatal outcomes, the probability of delay vaccination after 2 years of age for each antigen was highest in children born to women from Asia. The risk of missed vaccination for all antigens was significantly higher in children born to younger and unemployed women. CONCLUSIONS Factors related to area of origin (e.g., cultural habits, language skills) are likely to affect parents' decision to vaccinate their children. These factors, as well as sociodemographic characteristics, should be adequately investigated and addressed to increase vaccine uptake in foreign children, especially those born to Asian women.
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Affiliation(s)
- T Spadea
- Regional Epidemiology Unit, Asl TO3 Piedmont Region, Via Sabaudia 164, 10095, Grugliasco, Turin, Italy.
| | - V Fano
- Department of Prevention, Asl RM2, Via Maria Brighenti 23, 00159, Rome, Italy
| | - C Piovesan
- Department of Prevention, Ulss 2 Marca Trevigiana, Via S. Ambrogio di Fiera 37, 31100, Treviso, Italy
| | - R Rusciani
- Regional Epidemiology Unit, Asl TO3 Piedmont Region, Via Sabaudia 164, 10095, Grugliasco, Turin, Italy
| | - G Salamina
- Department of Hygiene and Public Health, Asl Città di Torino, Via Della Consolata 10, 10122, Turin, Italy
| | - G Greco
- Department of Hygiene and Public Health, Asl Città di Torino, Via Della Consolata 10, 10122, Turin, Italy
| | - G Colaiocco
- Department of Prevention, Asl RM2, Via Maria Brighenti 23, 00159, Rome, Italy
| | - M Ramigni
- Department of Prevention, Ulss 2 Marca Trevigiana, Via S. Ambrogio di Fiera 37, 31100, Treviso, Italy
| | - S Declich
- National Centre for Global Health, Italian National Institute of Health (ISS), Viale Regina Elena 299, 00161 Rome, Italy
| | - A Petrelli
- National Institute for Health, Migration, and Poverty (INMP), Via di S. Gallicano 25, 00153, Rome, Italy
| | - P Pezzotti
- Infectious Diseases Department, Italian National Institute of Health (ISS), Viale Regina Elena 299, 00161, Rome, Italy
| | - M Fabiani
- Infectious Diseases Department, Italian National Institute of Health (ISS), Viale Regina Elena 299, 00161, Rome, Italy
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11
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Vaccine hesitancy in the era of COVID-19. Public Health 2021; 194:245-251. [PMID: 33965796 PMCID: PMC7931735 DOI: 10.1016/j.puhe.2021.02.025] [Citation(s) in RCA: 578] [Impact Index Per Article: 192.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 12/14/2022]
Abstract
Objectives In 2019, a new coronavirus has been identified and many efforts have been directed toward the development of effective vaccines. However, the willingness for vaccination is deeply influenced by several factors. So the aim of our review was to analyze the theme of vaccine hesitancy during COVID-19 pandemic, with a particular focus on vaccine hesitancy toward COVID-19 vaccine. Study design Narrative review. Methods In November 2020, we performed a search for original peer-reviewed articles in the electronic database PubMed (MEDLINE). The key search terms were “Vaccine hesitancy AND COVID-19”. We searched for studies published during COVID-19 pandemic and reporting information about the phenomenon of vaccine hesitancy. Results Fifteen studies were included in the review. The percentage of COVID-19 vaccine acceptance was not so high (up to 86.1% students or 77.6% general population); for influenza vaccine, the maximum percentage was 69%. Several factors influenced the acceptance or refusal (ethnicity, working status, religiosity, politics, gender, age, education, income, etc.). The most given reasons to refuse vaccine were as follows: being against vaccines in general, concerns about safety/thinking that a vaccine produced in a rush is too dangerous, considering the vaccine useless because of the harmless nature of COVID-19, general lack of trust, doubts about the efficiency of the vaccine, belief to be already immunized, doubt about the provenience of vaccine. Conclusions The high vaccine hesitancy, also during COVID-19 pandemic, represents an important problem, and further efforts should be done to support people and give them correct information about vaccines.
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12
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Brunelli L, Valent F, Romanese F, Tricarico P, Pellizzaro A, d'Angelo M, Benetollo PP, Iob A, Forgiarini M, Brusaferro S. Parental trust and beliefs after the discovery of a six-year-long failure to vaccinate. Hum Vaccin Immunother 2021; 17:583-587. [PMID: 32750274 PMCID: PMC7899632 DOI: 10.1080/21645515.2020.1777820] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND In Italy vaccine hesitancy worsened after a failure to vaccinate episode that took place in Friuli Venezia-Giulia Region until early 2017 which undermined herd immunity by leaving unprotected more than 5,444 children. METHODS Between May and June 2017, 2,557 parents were surveyed at the local vaccination clinic where they were invited within the subsequent extraordinary vaccination campaign. The aim of the survey was to evaluate whether the multi-channel extraordinary vaccination campaign had reached the target population and to know parental beliefs and trusted sources of information after the failure to vaccinate event. RESULTS While 279 parents were non-hesitant (10.9%) and 1,491 hesitant acceptors (58.3%), just 38 (1.5%) refused to have their children revaccinated. Overall, the most consulted sources of information were print media (18.8%), physicians (16.0%), relatives and friends (12.1%). The majority of parents considered vaccination as a fundamental practice (73.9%), but many were worried about potential side effects (38.8%) or doubtful about the effectiveness of some vaccines (11.0%). According to parents, 19.7% of them (57) changed their opinion about vaccines after the Codroipo case. CONCLUSIONS After the Codroipo case, most parents chose to have their children re-vaccinated and just a little proportion refused the re-administration of vaccines. More studies are needed to confirm the importance of a coherent multi-channel communication strategy using both traditional and new media in order to counteract vaccine hesitancy.
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Affiliation(s)
- Laura Brunelli
- Dipartimento di Area Medica, Università Degli Studi di Udine , Udine, Italy
| | - Francesca Valent
- Istituto di Igiene Ed Epidemiologia Clinica, Azienda Sanitaria Universitaria Integrata di Udine , Udine, Italy
| | - Federico Romanese
- Dipartimento di Area Medica, Università Degli Studi di Udine , Udine, Italy
| | | | - Alice Pellizzaro
- Dipartimento di Area Medica, Università Degli Studi di Udine , Udine, Italy
| | - Matteo d'Angelo
- Dipartimento di Area Medica, Università Degli Studi di Udine , Udine, Italy
| | - Pier Paolo Benetollo
- Azienda per l'Assistenza Sanitaria No.3 Del Friuli Venezia Giulia , Gemona, Italy
| | - Andrea Iob
- Azienda per l'Assistenza Sanitaria No.3 Del Friuli Venezia Giulia , Gemona, Italy
| | - Mariarita Forgiarini
- Azienda per l'Assistenza Sanitaria No.3 Del Friuli Venezia Giulia , Gemona, Italy
| | - Silvio Brusaferro
- Dipartimento di Area Medica, Università Degli Studi di Udine , Udine, Italy
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13
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Socioeconomic Determinants in Vaccine Hesitancy and Vaccine Refusal in Italy. Vaccines (Basel) 2020; 8:vaccines8020276. [PMID: 32516936 PMCID: PMC7349972 DOI: 10.3390/vaccines8020276] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 05/26/2020] [Accepted: 06/02/2020] [Indexed: 01/21/2023] Open
Abstract
Childhood vaccination has been a milestone in the control of infectious diseases. However, even in countries offering equal access to vaccination, a number of vaccine-preventable diseases have re-emerged. Suboptimal vaccination coverage has been called into question. The aim was to explore socioeconomic inequalities in vaccine hesitancy and outright refusal. Families with at least one child aged between 3 months and 7 years were involved through an online survey. Families were classified as provaccine, hesitant, or antivaccine. The association between socioeconomic determinants and hesitancy/refusal was investigated with a logistic-regression model. A total of 3865 questionnaires were collected: 64.0% of families were provaccine, 32.4% hesitant, and 3.6% antivaccine. Rising levels of perceived economic hardship were associated with hesitancy (adjusted odds ratio (AOR) from 1.34 to 1.59), and lower parental education was significantly associated with refusal (AOR from 1.89 to 3.39). Family economic hardship and parental education did not move in parallel. Economic hardship was a determinant of hesitancy. Lower education was a predictor of outright refusal without affecting hesitancy. These findings may serve as warnings, and further explanations of socioeconomic inequities are needed even in universal healthcare systems. Insight into these factors is necessary to improve convenience and remove potential access issues.
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14
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Pacenti M, Maione N, Lavezzo E, Franchin E, Dal Bello F, Gottardello L, Barzon L. Measles Virus Infection and Immunity in a Suboptimal Vaccination Coverage Setting. Vaccines (Basel) 2019; 7:vaccines7040199. [PMID: 31795157 PMCID: PMC6963570 DOI: 10.3390/vaccines7040199] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 11/23/2019] [Accepted: 11/26/2019] [Indexed: 11/24/2022] Open
Abstract
Despite efforts to improve surveillance and vaccination coverage, measles virus (MeV) continues to cause outbreaks also in high-income countries. As the reference laboratory of the Veneto Region, Italy, we analyzed changes in population immunity, described measles outbreaks, investigated MeV genetic diversity, and evaluated cross-protection of measles vaccination against MeV epidemic strains. Like most European areas, the Veneto Region has suboptimal measles vaccination coverage and is facing a growing public mistrust of vaccination. A progressive decline of measles vaccine uptake was observed during the last decade in the Veneto Region, leading to immunity gaps in children and young adults. Measles outbreaks were caused by the same MeV genotype B3, D4, and D8 strains that were circulating in other European countries. Eleven cases of measles were observed in immunized subjects. These cases were not associated with particular MeV genotypes nor with mutations in epitopes recognized by neutralizing antibodies. Accordingly, sera from fully vaccinated subjects cross-neutralized epidemic MeV strains, including the genotypes B3, D4, and D8, with the same high efficiency demonstrated against the vaccine strain. In fully vaccinated subjects, high MeV IgG antibody titers persisted up to 30 years following vaccination. These results support the use of the current measles-containing vaccines and strategies to strengthen vaccination.
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Affiliation(s)
- Monia Pacenti
- Microbiology and Virology Unit, Padova University Hospital, 35128 Padova, Italy; (M.P.); (E.F.); (F.D.B.)
| | - Nataskya Maione
- Department of Molecular Medicine, University of Padova, 35121 Padova, Italy; (N.M.); (E.L.)
| | - Enrico Lavezzo
- Department of Molecular Medicine, University of Padova, 35121 Padova, Italy; (N.M.); (E.L.)
| | - Elisa Franchin
- Microbiology and Virology Unit, Padova University Hospital, 35128 Padova, Italy; (M.P.); (E.F.); (F.D.B.)
- Department of Molecular Medicine, University of Padova, 35121 Padova, Italy; (N.M.); (E.L.)
| | - Federico Dal Bello
- Microbiology and Virology Unit, Padova University Hospital, 35128 Padova, Italy; (M.P.); (E.F.); (F.D.B.)
- Department of Molecular Medicine, University of Padova, 35121 Padova, Italy; (N.M.); (E.L.)
| | - Lorena Gottardello
- Department of Hygiene and Public Health, Azienda ULSS 6 Euganea, 35131 Padova, Italy;
| | - Luisa Barzon
- Microbiology and Virology Unit, Padova University Hospital, 35128 Padova, Italy; (M.P.); (E.F.); (F.D.B.)
- Department of Molecular Medicine, University of Padova, 35121 Padova, Italy; (N.M.); (E.L.)
- Correspondence: ; Tel.: +39-049-821-8946
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15
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Arat A, Burström B, Östberg V, Hjern A. Social inequities in vaccination coverage among infants and pre-school children in Europe and Australia - a systematic review. BMC Public Health 2019; 19:290. [PMID: 30866881 PMCID: PMC6417277 DOI: 10.1186/s12889-019-6597-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 02/25/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Herd immunity levels of vaccine uptake are still not reached in some high-income countries, usually in countries with persisting social inequities in uptake. Previous studies have focused on factors within one health care system. This study takes a broader health care systems approach by reviewing the socioeconomic distribution of vaccination coverage on the national level in light of structural and organizational differences of primary care for children. METHODS A systematic literature review of socio-economic patterns of uptake of Measles-Mumps-Rubella (MMR) and/or Diphteria-Tetanus-Pertusis (DTP) in population based studies of children 0-5 years of age living in the 30 European Economic Area (EEA) or European Free Trade Association (EFTA) countries and Australia, was carried out using the PRISMA guidelines. The health care system in the countries in the study were categorized by degree of freedom of the primary care provider (hierarchical or non-hierarchical) and whether preventive services were provided in a separate organization (well-baby clinics). RESULTS The review identified 15 studies from 10 European countries and Australia that fulfilled the criteria. Although the heterogeneity of the socio-economic indicators did not allow for a conclusive meta-analysis, the study pointed towards lower levels of inequities in primary care models with well-baby clinics. In non-hierarchical primary care organizations that also lacked well-baby clinics, socioeconomic gaps in uptake were often found to be large. CONCLUSION This review indicates that structural and organizational aspects of health care systems for young children are important for equity in vaccine uptake.
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Affiliation(s)
- Arzu Arat
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Centre for Health Equity Studies, Karolinska Institutet/Stockholm University, SE-106 91 Stockholm, Sweden
| | - Bo Burström
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Viveca Östberg
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
| | - Anders Hjern
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Centre for Health Equity Studies, Karolinska Institutet/Stockholm University, SE-106 91 Stockholm, Sweden
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16
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Nozaki I, Hachiya M, Kitamura T. Factors influencing basic vaccination coverage in Myanmar: secondary analysis of 2015 Myanmar demographic and health survey data. BMC Public Health 2019; 19:242. [PMID: 30819127 PMCID: PMC6394082 DOI: 10.1186/s12889-019-6548-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 02/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Immunization is one of the most effective measures for preventing disease when vaccination coverage is sufficient. Although vaccination coverage is known to be influenced by social and cultural barriers, the determinants of childhood immunization in Myanmar remain poorly understood. This study analyzed factors that influenced complete vaccination status (one dose each for Bacillus Calmette-Guérin and measles and three doses each for diphtheria-pertussis and polio) using 2015 data from the Myanmar Demographic Health and Survey. METHODS Data from 12 to 23-month-old children and their mothers were extracted from the nationally representative survey results. Bivariate and multivariate analyses with survey-weighted logistic regression were performed to examine the relationships between vaccination status and various sociodemographic and medical factors. The independent variables for the analyses included area of residence, economic status, maternal age, marital status, education, literacy, employment status, antenatal care attendance, tetanus vaccination, place of delivery, postnatal evaluations, child's sex, number of children, previous child death, decision maker(s) regarding child's health, frequency of healthcare visits, paternal education, and paternal occupation. RESULTS A representative sample of 904 cases were extracted for the analysis. The overall complete vaccination rate was 55.4%. In the multivariate analysis with backward step-wise selection, complete vaccination was independently associated with middle or high economic status (adjusted odds ratio [AOR]: 2.64, 95% confidence interval [CI]: 1.85-3.78), older maternal age (AOR: 2.87, 95% CI: 1.62-5.10), ≥4 antenatal care visits (AOR: 1.87, 95% CI: 1.28-2.73), and maternal tetanus vaccination before delivery (AOR: 3.26, 95% CI: 1.82-5.85). CONCLUSION The first Demographic and Health Survey in Myanmar revealed that only approximately one-half of 12-23-year-old children had received complete vaccination, which was lower than the estimated rate from routine administrative coverage. Our results indicate that incomplete immunization status was associated with low economic status, younger maternal age, fewer antenatal care visits, and no maternal tetanus vaccination. These findings may help improve the targeting and strategic implementation of the Expanded Programme on Immunization.
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Affiliation(s)
- Ikuma Nozaki
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku, Tokyo, 162-8655, Japan. .,Ministry of Health, Naypyidaw, Myanmar.
| | - Masahiko Hachiya
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku, Tokyo, 162-8655, Japan
| | - Tomomi Kitamura
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku, Tokyo, 162-8655, Japan
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17
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Giuliani AR, Mattei A, Appetiti A, Pompei D, Di Donna F, Fiasca F, Fabiani L. Spontanuous Demand For Meningococcal B Vaccination: Effects On Appropriateness And Timing. Hum Vaccin Immunother 2018; 14:2075-2081. [PMID: 29927693 PMCID: PMC6150011 DOI: 10.1080/21645515.2018.1466015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
When the meningococcus B vaccine was introduced into Italy in 2017, it was recommended for newborns based on national epidemiological data indicating that they were at greater risk. However, the vaccination service of the local health authority of L'Aquila had already been receiving spontaneous parental requests to provide vaccination for children in lower-risk age groups from the beginning of 2016. We therefore decided to use a self-administered questionnaire in order to investigate the parents’ socio-demographic data; their children's history of other recommended vaccinations (against measles, mumps and rubella, varicella, meningococcus C and, for females, human papilloma virus); the information sources concerning meningococcal vaccination; and the timing of its administration. The questionnaire was completed by 565 parents, and the results showed that the requests mainly came from the parents of children aged 5–11 years. The children whose mothers had received a high school education and were >35 years old were more likely to have received the first dose after the age of one year and to have perceived pain at the inoculation site, and less likely to have experienced mild general reactions. The requests were mainly trigged by the recommendations of healthcare professionals, and the overloading of the vaccination service led to delays in the administration of the doses after the first. The delays (reported by 74.07% of the parents) were mainly due to organisational problems in the service itself, which led 61.52% of the doses being more appropriately administered by staff working as private physicians inside public health facilities, albeit at extra cost. These findings indicate that organisational factors and excessive demand had a considerable impact on both the efficacy of the immunisation and its appropriateness.
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Affiliation(s)
- A R Giuliani
- a Department of Life , Health and Environmental Sciences, University of L'Aquila , Italy
| | - A Mattei
- a Department of Life , Health and Environmental Sciences, University of L'Aquila , Italy
| | - A Appetiti
- a Department of Life , Health and Environmental Sciences, University of L'Aquila , Italy
| | - D Pompei
- b Abruzzo Regional Department of Prevention (ASL1) , L'Aquila , Italy
| | - F Di Donna
- a Department of Life , Health and Environmental Sciences, University of L'Aquila , Italy
| | - F Fiasca
- a Department of Life , Health and Environmental Sciences, University of L'Aquila , Italy
| | - L Fabiani
- a Department of Life , Health and Environmental Sciences, University of L'Aquila , Italy
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18
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County-level assessment of United States kindergarten vaccination rates for measles mumps rubella (MMR) for the 2014–2015 school year. Vaccine 2017; 35:6444-6450. [DOI: 10.1016/j.vaccine.2017.09.080] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 09/24/2017] [Accepted: 09/25/2017] [Indexed: 11/18/2022]
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