What is 'confidence' and what could affect it?: A qualitative study of mothers who are hesitant about vaccines

Evaluating the impact of short animated videos on COVID-19 vaccine hesitancy: An online randomized controlled trial

Addressing the global challenge of vaccine hesitancy, amplified during the COVID-19 pandemic due to misinformation propagated via social media, necessitates innovative health communication strategies. This investigation scrutinizes the efficacy of Short, Animated, Story-based (SAS) videos in fostering knowledge, behavioral intent, and engagement around COVID-19 vaccination. We conducted an online three-arm parallel randomized controlled trial (RCT) involving 792 adult participants (≥18 years, English-speaking) from the United States. The intervention group viewed a SAS video on COVID-19 vaccination, the attention placebo control group watched a SAS video on hope, and the control group received no intervention. Our primary objectives were to assess the influence of SAS videos on knowledge, behavioral intent, and engagement regarding COVID-19 vaccination. Participants in the intervention group displayed significantly higher mean knowledge scores (20.6, 95 % CI: 20.3-20.9) compared to both the attention placebo control (18.8, 95 % CI: 18.5-19.1, P < .001) and control groups (18.7, 95 % CI: 18.4-19.0, P < .001). However, SAS videos did not notably affect behavioral intent. Perception of COVID-19 as a significant health threat emerged as a strong predictor for engaging with the post-trial video without further incentives (OR: 0.44; 95 % CI: 0.2-0.96). The 35-44 age group exhibited the highest post-trial engagement (P = .006), whereas right-wing political inclination negatively associated with engagement (OR: 1.98; 95 % CI: 3.9-1.01). Vaccination status correlated significantly with self-efficacy (P < .001), perceived social norms (P < .001), and perceived response efficacy of the COVID-19 vaccine (P < .001), all heightened in the intervention group. These findings suggest that while SAS videos effectively amplify COVID-19 vaccination knowledge, their impact on behavioral intent is not direct. They do, however, affect determinants of vaccination status, thereby indirectly influencing vaccination behavior. The study highlights the appeal of SAS videos among younger audiences, but underscores the need for further examination of factors impeding vaccination engagement. As SAS videos closely mirror conventional social media content, they hold significant potential as a public health communication tool on these platforms. Trial Registration: Trial was registered at drks.de with the identifier DRKS00027938, on 5 January 2022.

University students' willingness to receive a COVID-19 vaccine in the United States

The disproportionate number of COVID-19 cases and deaths in the United States (US) requires understanding of health behaviors that contributed to low acceptance of public health guidelines. University students were at low risk for complications from COVID-19 infections but at high-risk for infecting others. It is important to understand which characteristics influenced willingness to receive the COVID-19 vaccine. The purpose of this cross-sectional study was to explore the social factors and identities that predicted university students' willingness to receive COVID-19 vaccines before one was available. This study used a stratified random sample from a Midwestern public university in 2020 (N = 614). Results suggest hesitancy toward childhood vaccinations, noncompliance with mask-wearing and large-group-avoidance guidelines, and conservative political ideology increased the odds of being unwilling to receive a COVID-19 vaccination. However, higher subjective social status and male gender increased the odds of being willing to be vaccinated.

A taxonomy of anti-vaccination arguments from a systematic literature review and text modelling

The proliferation of anti-vaccination arguments is a threat to the success of many immunization programmes. Effective rebuttal of contrarian arguments requires an approach that goes beyond addressing flaws in the arguments, by also considering the attitude roots-that is, the underlying psychological attributes driving a person's belief-of opposition to vaccines. Here, through a pre-registered systematic literature review of 152 scientific articles and thematic analysis of anti-vaccination arguments, we developed a hierarchical taxonomy that relates common arguments and themes to 11 attitude roots that explain why an individual might express opposition to vaccination. We further validated our taxonomy on coronavirus disease 2019 anti-vaccination misinformation, through a combination of human coding and machine learning using natural language processing algorithms. Overall, the taxonomy serves as a theoretical framework to link expressed opposition of vaccines to their underlying psychological processes. This enables future work to develop targeted rebuttals and other interventions that address the underlying motives of anti-vaccination arguments.

Decision making in vaccine hesitant parents and pregnant women - An integrative review

Objectives

: Vaccine refusal is increasing in Australia and is a major concern in high- and middle-income countries. There is evidence to suggest that some parents, even those who elect to immunise, may be vaccine hesitant with some manipulating the schedule by excluding or delaying some vaccines. The aim of this review was to gain an understanding of factors that influence vaccine decision-making in pregnant women and parents of children.

Design

: An integrative review approach was used to produce an analysis of existing literature on vaccine decision-making in pregnancy and parents. As the broadest of review methods, an integrative review can include a range of experimental and non-experimental research, thereby ensuring the inclusion of data from multiple perspectives.

Data Sources

: Online databases were searched for research related to vaccine decision-making in pregnant women and parents. Original and review articles were sought that were published in English between 2015 and 2021. Reviewed articles included qualitative and quantitative studies and systematic reviews. No mixed methods papers were located or excluded from this review.

Review methods

: The review method was an integrative review informed by Coughlan.

Results

: Papers from thirteen predominantly high- and middle-income countries were selected for this review. A total of 31 articles fit the inclusion/exclusion criteria, including qualitative, quantitative and review articles. Three main themes were identified including the role of healthcare professionals, vaccine safety concerns and alternative influences. Alternative influences included: social media, friends and family, religion, conspiracy theories and salutogenic parenting. Findings suggest that high levels of anxiety are involved in vaccine decision-making with parents seeking information from multiple sources including healthcare professionals, friends and family and social media.

Conclusions

: Pregnancy is an ideal time to provide education on both pregnancy and childhood vaccinations. However, some parents reported dissatisfaction in their therapeutic relationships with healthcare professionals. As a result, parents can resort to their own information seeking, in the main via social media which has been linked to vaccine refusal. Additionally, some healthcare professionals report feeling inadequately prepared for the role of immunisation promotion and provision. Parental information seeking from non-traditional sources has been shown to result in the acquisition of misinformation, exposure to conspiracy theories, the inevitable loss of vaccine confidence and subsequent vaccine refusal.

Factors affecting childhood immunization: Thematic analysis of parents and healthcare workers' perceptions

Immunization against common childhood diseases is an important strategy as it is critical for reducing the global child morbidity and mortality. This review explores the perceptions of parents and HCWs toward childhood immunization. The PRISMA guideline was used to search and include the studies. Relevant electronic databases were systemically searched for the years ranging from 2000 to 2021 to identify studies reported in English. Themes were then identified using thematic analysis. A total of 44 studies met the review criteria and were summarized and categorized into 4 themes: barriers to immunization, parental knowledge, attitude and behavior (KAB), health system factors and HCWs' KAB. This review found that immunization decision-making is a complex process. Parental KAB leads to immunization decisions. HCWs were also noted to be the trusted sources of immunization information. Further research can be conducted on how to improve parents' perceptions of immunization and immunization practices.

A Social Cognitive Theory Approach to Understanding Parental Attitudes and Intentions to Vaccinate Children during the COVID-19 Pandemic

The distribution of the COVID-19 vaccine represents a path towards global health after a worldwide pandemic. Yet, the U.S. response to the vaccination rollout has been politically polarized. The aim of this paper is to contribute to the understanding of the contextual factors that influence parents' attitudes towards health officials and their intention to vaccinate children, focusing on communication behaviors, personal factors, and geographic locations. We use Bandura's triadic reciprocal determinism (TRD) model which posits reciprocal influence between personal factors, environmental factors, and behaviors. We found that personal factors (having younger children and identifying as Republican partisans), and the behavioral factor of conservative news use were significantly related to more negative attitudes towards health officials and lower vaccination intentions. Conversely, Democrats and liberal news use were significantly related to warmer attitudes and greater vaccination intentions. The environmental factor of geographic location across four states with different partisan dynamics was not significantly related to attitudes and behavioral intentions. Results from a post-hoc analysis show that news media use and partisanship were the strongest correlates of parents' attitudes towards health officials. This evidence points to the politicization of the COVID-19 vaccine being a key consideration regarding vaccine uptake.

COVID-19 vaccine hesitancy in Sana'a, Yemen

Background and Aim: The development of a coronavirus disease 2019 (COVID-19) vaccine is ongoing. This study aimed to prepare for public acceptance of the vaccine. There is a need to identify the current acceptance and potential barriers to receiving a COVID-19 vaccine in Yemen. Understanding the hesitancy and acceptance of a COVID-19 vaccine are crucial to develop local evidence-based interventions. Materials and Methods: Twenty students were interviewed in this study. An interview guide was developed and it addressed the willingness to accept a future COVID-19 vaccine. In-depth interviews were conducted, transcribed, and manually analyzed. Results: The majority of participants agreed that they would take a COVID-19 vaccine for several reasons, including protection for themselves, their families, and others and to stop the spread of COVID-19, for which the vaccine is important, as in other routine vaccinations. However, some participants shared that they would not take the COVID-19 vaccine due to the following reasons: Concerns regarding the safety of the vaccine; feeling fit and healthy, and thus considering themselves to have strong immunity; feeling that the vaccine was manufactured in a rushed manner and thus it would require approval by the World Health Organization; being previously infected with COVID-19 and considering themselves protected, and placing their trust in God and believing no vaccine was needed. Conclusion: The willingness to receive a future COVID-19 vaccine was high among medical students. However, some students hesitated to take the vaccine. Therefore, mass media interventions are required to maximize vaccine uptake.

Parental gender differences in attitudes and willingness to vaccinate against COVID-19

AIMS

COVID-19 affects family life world-wide. Determinants of hesitancy around vaccinating children against COVID-19 are critical in guiding public health campaigns. Gender differences among parents may determine willingness to vaccinate children against COVID-19.

METHODS

Secondary analysis of the COVID-19 Parental Attitude Study (COVIPAS) surveying care givers of children presenting for emergency care in 17 sites in 6 countries during peak pandemic (March-June, 2020). We assessed risk perceptions, vaccination history and plans to vaccinate children against COVID-19 once available. We compared responses given by father or mother and used multivariable logistic regression.

RESULTS

A total of 2025 (75.4%) surveys were completed by mothers and 662 (24.6%) by fathers, 60 did not respond to question about future vaccination. Of 2627, 1721 (65.5%) were willing to vaccinate their children. In the multivariable analysis, both fathers and mothers were more willing to vaccinate their child if the parent was older and believed that social distancing is worthwhile, and if their child was up-to-date on childhood vaccines (odds ratio (OR) of 1.02, 3.90, 1.65 for mothers and 1.04, 4.76, 2.87 for fathers, respectively). Mothers (but not fathers) were more willing if they had more than a high school education (OR 1.38), and fathers (but not mothers) were more willing to vaccinate their male children (OR 1.62), compared to female children.

CONCLUSION

Unique differences between mothers and fathers underscore the need to view vaccine hesitancy as an acceptable parental response. Public health should plan targeted educational information for parents about a COVID-19 vaccine for children.

The Role of General Attitudes and Perceptions Towards Vaccination on the Newly-Developed Vaccine: Results From a Survey on COVID-19 Vaccine Acceptance in China

Background

Vaccination has been considered one of the most effective public health interventions. In the context of the global epidemic of coronavirus disease 2019 (COVID-19), it remains unclear what role general vaccination attitudes and perceptions have on the acceptance of COVID-19 vaccine.

Objective

This study aims to explore the impact of general attitudes and perceptions toward vaccination on the acceptance of a newly developed vaccine, taking COVID-19 vaccines as an example.

Method

A cross-sectional survey was conducted among 2,013 Chinese adult participants. Generalized order logistic regression and path analysis models were used to analyze impacts of general attitudes and perceptions toward vaccination on the acceptance of the COVID-19 vaccine.

Results

The prevalence of hesitancy to vaccination in general is 49.9% among the Chinese adult population. General perceptions of vaccination were associated with corresponding perceptions of the COVID-19 vaccine. A “no hesitancy” attitude toward vaccination is a significant determinant (aOR = 1.77, 95% CI = 1.36–2.31) of future COVID-19 vaccination compared to vaccine refusers, and perceptions of COVID-19 vaccine remain a significant determinant for the acceptance of the COVID-19 vaccine. Path analysis indicates that perceptions of the importance and safety of vaccination have a positive overall effect on the acceptance of the COVID-19 vaccine, and that general perceptions of vaccination as a whole on each measure indirectly influence the acceptance of the COVID-19 vaccine.

Conclusion

General attitudes and perceptions toward vaccination were associated with those of the COVID-19 vaccine and future vaccination intention. To prepare for possible emergence of diseases in the future, routine health campaigns should be launched by relevant government departments and vaccination authorities to enhance the overall awareness and knowledge of vaccination among the public and to ensure optimal vaccination experience. In addition, targeted knowledge dissemination and mass mobilizations should be urged for newly developed vaccines when some specific infectious diseases emerge, such as COVID-19 at present.

The last stretch: Barriers to and facilitators of full immunization among children in Nepal’s Makwanpur District, results from a qualitative study

Background

Approximately 35% of Nepal’s children have not received all recommended vaccines, and barriers to immunization exist on both the demand- (i.e., access, affordability, acceptance) and supply- (i.e., logistics, infrastructure) sides.

Objective

This article describes a formative study to understand the barriers to and facilitators of immunization in Makwanpur, Nepal from both the demand- and supply-sides.

Methods

Through in-depth interviews, key informant interviews, and focus group discussions (N = 76), we assessed knowledge, attitudes, and experiences with immunization; social norms related to immunization; perceptions of local health facilities; and descriptions of client-provider relationships. Data were analyzed using an iterative, grounded theory approach.

Results

Three major themes emerged, including positive demand of vaccines, lack of mutual trust between service seekers and service providers, and internal and external motivators of vaccine supply. On the demand-side, caregivers reported high levels of immunization-related awareness, knowledge, and acceptance, largely perceived to be due to a generational shift. On the supply-side, providers expressed passion for their work despite lack of support from local authorities and a desire for more training. Between caregivers and providers, lack of mutual trust emerged as a prominent barrier, revealing a cycle of positive service bias.

Conclusions

We identified mutual trust as a key pathway toward reaching full immunization coverage in Nepal and we recommend future interventions adopt an approach which focuses on removing social barriers (i.e., distrust) and structural barriers (i.e., opening hours, neglected infrastructure) to immunization.

The Role of Recipient Characteristics in Health Video Communication Outcomes: Scoping Review

BACKGROUND

The importance of effective communication during public health emergencies has been highlighted by the World Health Organization, and it has published guidelines for effective communication in such situations. With video being a popular medium, video communication has been a growing area of study over the past decades and is increasingly used across different sectors and disciplines, including health. Health-related video communication gained momentum during the SARS-CoV-2 pandemic, and video was among the most frequently used modes of communication worldwide. However, although much research has been done regarding different characteristics of video content (the message) and its delivery (the messenger), there is a lack of knowledge about the role played by the characteristics of the recipients for the creation of effective communication.

OBJECTIVE

The aim of this review is to identify how health video communication outcomes are shaped by recipient characteristics, as such characteristics might affect the effectiveness of communication. The main research question of the study is as follows: do the characteristics of the recipients of health videos affect the outcomes of the communication?

METHODS

A scoping review describing the existing knowledge within the field was conducted. We searched for literature in 3 databases (PubMed, Scopus, and Embase) and defined eligibility criteria based on the relevance to the research question. Recipient characteristics and health video communication outcomes were identified and classified.

RESULTS

Of the 1040 documents initially identified, 128 (12.31%) met the criteria for full-text assessment, and 39 (3.75%) met the inclusion criteria. The included studies reported 56 recipient characteristics and 42 communication outcomes. The reported associations between characteristics and outcomes were identified, and the potential research opportunities were discussed. Contributions were made to theory development by amending the existing framework of the Integrated-Change model, which is an integrated model of motivational and behavioral change.

CONCLUSIONS

Although several recipient characteristics and health video communication outcomes were identified, there is a lack of robust empirical evidence on the association between them. Further research is needed to understand how the preceding characteristics of the recipients might affect the various outcomes of health video communication.

Prevalence, Trends and Conditions for the DTP3 Vaccine: A 25-Year Historical Perspective

Background

The aim was to verify the prevalence of vaccination coverage, tendency and factors of the third dose of the vaccine against diphtheria, tetanus and pertussis-DTP3 in surveys over the period of 25 years in a state of the Northeast of Brazil.

Methods

Cross-sectional and temporal series, utilizing ad hoc database, were extracted from the Health and Nutrition State Research 1991, 1997, 2006 and 2015/2016. Children from 12 to 23 months of age with proof in the vaccination card were included. The vaccination coverage (outcome) of each year was calculated, the tendency throughout the period was analyzed and the associations through Pearson chi-squared were tested. The results of the first and last survey were compared with a significance level of 5%. The reasons of the crude prevalence and confidence intervals of 95% were estimated.

Results

The vaccination coverage in 1991, 1997, 2006 and 2015/2016 was 77.6%, 82.7%, 89.7% and 72.9%, respectively, with an increasing tendency from 1991 to 2006 (p<0.001) and decreasing between 2006 and 2015/2016 (p<0.001). Factors in 1991: low socioeconomic conditions; lack of access to health service and pre-natal care, nutritional deficit and diarrhea in children (p<0.005). In 2015/2016, low socioeconomic conditions and diarrhea persisted and a larger family size, black, negative self-perception of happiness, both from the mother (p<0.05), were identified.

Conclusion

The factors of the recent decrease of vaccination coverage are complex, multifactorial, dependent of context and even on subjective aspects of the maternal perception. Its identification contributed to the understanding of inadequate vaccination at the state level.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Maximizing Completion of the Two-Dose COVID-19 Vaccine Series with Aid from Infographics

Two of the three COVID-19 vaccines approved in the United States require two doses to reach full efficacy, as do others available elsewhere in the world. The complete series of multidose COVID-19 vaccines offers stronger protection against infection by SARS-CoV-2 compared to single-dose injections with the same vaccines. Achieving perfect community-level adherence is a challenge in any public health campaign, even in non-pandemic times. Vaccines requiring multiple doses combined with a surge of vaccine hesitancy and misinformation that has been witnessed by the public during the COVID-19 pandemic are exacerbating the challenge of ensuring the world’s population achieves a sufficient level of immunity against COVID-19. Here, we describe the results of our study in which we sought to determine whether completion of a two-dose COVID-19 vaccine regimen could be improved by disseminating infographics that explain what the vaccine is and why returning for the second dose is beneficial. Our results show that the proportion of COVID-19 vaccine recipients returning for a second inoculation grew after COVID-19 vaccine infographics were distributed to first-time vaccine recipients. We suggest that extending communication and outreach initiatives into the clinic positively influences the rate of follow-up visits, and that infographics are useful tools to aid and bolster the deployment of COVID-19 vaccines.

Parental experiences of caring for their preschool children after declining vaccines: a qualitative systematic review protocol

OBJECTIVE

This review will explore the experiences of parents after making the decision not to vaccinate their young children. This review aims to help health care providers understand parents' specific care strategies for their under-vaccinated or unvaccinated young children.

INTRODUCTION

Much of the current qualitative research literature on parents who hesitate or refuse to vaccinate their young children focuses on parental perceptions about the safety and efficacy of vaccines and decision-making. However, limited attention has been paid to measures taken by parents to help their young children avoid contracting communicable diseases, promote resistance, and enhance their children's health.

INCLUSION CRITERIA

This review will consider qualitative studies that describe parents' experiences of caring for their young children, aged 0 to 6 years, after making the decision not to vaccinate. Studies undertaken in any context will be considered. Studies that focus on young children who are unvaccinated or not fully vaccinated for reasons not related to parental refusal will be excluded.

METHODS

The JBI methodology for systematic reviews of qualitative evidence will be followed. Databases will be searched from 1998 onwards, and will include Web of Science, MEDLINE, CINAHL, PsycINFO, Google Scholar, and ProQuest Dissertations and Theses, with no language limits. Following critical appraisal, findings that describe parental experiences and the care activities they perform related to their young children will be extracted. The JBI process of meta-aggregation will be used to identify categories and synthesize findings. The ConQual approach will be used to assess confidence in the findings.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021241781.

Using a Harm Reduction Model to Reduce Barriers to Vaccine Administration

Vaccination is a strategic public health measure designed to reduce the adverse effects of many infectious diseases. Although national recommendations exist for vaccine administration across the life span, immunization rates are affected by barriers to vaccine access and hesitancy in vaccine acceptance. Midwives and women's health clinicians are optimally poised to assess their client's vaccination status and provide vaccinations during clinical encounters. In order to address client concerns about vaccine safety and administration, each clinician is expected to be knowledgeable about vaccine benefits, recommendations, side effects, and potential adverse reactions. Socioeconomic factors, social policies, and historic and continued experiences related to racism have been identified as barriers to ready access to vaccinations and vaccine acceptance. Midwives can act as leaders within their practice sites and communities through participation in projects that reduce barriers to vaccine access and uptake. Community vaccine outreach programs and relationship-based care can increase vaccine uptake through improved health literacy and associated behavioral changes including greater vaccine acceptance. This article focuses on identifying barriers to vaccine uptake and describing harm reduction measures designed to improve uptake of vaccines. A variety of leadership activities are discussed that can improve clinicians' understanding of their role in optimizing vaccination.

Vaccination coverage estimates and utilization patterns of inactivated enterovirus 71 vaccine post vaccine introduction in Ningbo, China

Background

In China, enterovirus 71 (EV71) is the major etiological agents of hand foot mouth disease that poses severe risks to children’s health. Since 2015, three inactivated EV71 vaccines have been approved for use. Previous studies indicated the high willingness of EV71 vaccination in eastern China. However, few studies have assessed coverage and utilization patterns of EV71 vaccine in China.

Methods

Children born during 2012–2018 were sampled and their records were abstracted from Ningbo childhood immunization information management system. Descriptive statistics characterized the study population and assessed coverage and timeliness for EV71 vaccination. Simultaneous administration patterns as well as type of EV71 vaccine used were also evaluated. Bivariate and multivariable analysis was used to examine the relationship of socio-demographic characteristics with vaccination coverage and timeliness.

Results

Of 716,178 children living in Ningbo. One hundred seventy-two thousand two hundred thirty-six received EV71 vaccine with a coverage rate of 24.05% and only 8.61% received vaccination timely. 21.97% of children received the complete two dose EV71 series but only 6.49% completed timely. Vaccination coverage and timeliness increased significantly from 2012 birth cohort to 2018 birth cohort. Relatively higher coverage and timeliness were observed in resident children, Inner districts, high socioeconomic areas and large-scaled immunization clinics. Of 329,569 doses of EV71 vaccine, only 5853(1.78%) doses were administered at the same day as other vaccines.

Conclusions

There is a need for increasing EV71 vaccination coverage and timeliness as well as eliminating disparities among different populations. Our study highlights the importance of simultaneous administration to increasing coverage and timeliness of EV71 vaccination.

Effective interventions to increase routine childhood immunization coverage in low socioeconomic status communities in developed countries: A systematic review and critical appraisal of peer-reviewed literature

OBJECTIVES

Childhood immunization coverage rates are known to be disproportionate according to population's socioeconomic status (SES). This systematic review examined and appraised quality of interventions deemed effective to increase routine childhood immunization uptake in low SES populations in developed countries.

METHODS

A literature search was conducted using Medline, Embase, CINAHL, EBMR, PsycInfo, PubMed, and Health STAR. We systematically searched and critically appraised articles published between January 1990 and December 2019 using the Effective Public Health Practice Project Quality Assessment tool. This systematic review provides a synthesis of the available evidence for childhood immunization interventions deemed effective for low SES parents or families of children ≤ 5 years of age.

SYNTHESIS

The search yielded 3317 records, of which 2975 studies met the inclusion criteria. From the 100 relevant studies, a total of 40 were included. The majority of effective and strongly rated studies synthesized consisted of multi-component interventions. Such interventions addressed access, community-based mobilization, outreach, appointment reminders, education, clinical tracking and incentives, and were language and health literacy appropriate to support low SES parents. Improving access to low SES parents was deemed effective in the vast majority of strongly rated studies. Incorrect contact information of low SES parents due to increased social mobility (i.e. household moves) rendered reminders ineffective, and therefore, updating contact information should be pursued proactively by front-line healthcare providers. In addition, plain language communication with low SES parents regarding immunization was deemed effective in improving immunization uptake.

CONCLUSION

Comprehensive multi-component interventions including improved access, appointment reminders, education and precision health communication are effective for addressing health inequities in immunization coverage amongst marginalized populations. Most low SES parents still believe that the benefits of immunization outweigh the risks.

Vaccines and autism: a preliminary qualitative study on the beliefs of concerned mothers in Italy

Purpose: While a large body of evidence has shown that the administration of the measles-mumps-rubella (MMR) vaccine is not associated with an increased risk of autism spectrum disorder (ASD), a hesitant attitude towards childhood vaccination is still present among the public. In this study, we aim to investigate the mothers’ perceptions of the cause of their child’s ASD in order to increase our understanding of vaccine hesitancy.

Methods: This study draws on the analysis of 18 semi-structured interviews of mothers of children with ASD on the causes of autism.

Results: The interview material was content-analysed. The main themes were 1) childhood vaccines; 2) genetics; 3) specific conditions of the mother or the newborn at the moment of delivery; 4) environmental factors such as the mother’s lifestyle or her diet. The link between vaccines and autism was prevalent. About one third of the mothers reported that their child’s ASD was a consequence of a combination of two or more factors, i.e., childhood vaccines and specific conditions of the newborn or the mother at the moment of delivery.

Conclusion: This study provides preliminary insights into recurring sets of beliefs concerning the causes of ASD among the mothers of affected children.

Vaccination Status and Attitude among Measles Cluster Cases in Austria, 2019

On 21 January 2019, public health authorities of two neighboring Austrian provinces reported an increase in measles cases. We investigated this occurrence to identify clusters of epidemiologically linked cases and the associated vaccination status in order to generate hypotheses on those factors explaining the size of the measles clusters. Probable cases were residents of the provinces of Styria or Salzburg with clinical presentation of measles after 1 January 2019 who were linked to a confirmed case using RNA virus detection. We collected data on age, rash onset, certificate-based vaccination status and reasons for being unvaccinated. Contact history was used to identify chains of transmission. By 11 March, we identified 47 cases, with 40 (85.1%) in unvaccinated patients. A cluster of 35 cases with a median age of seven years (IQR: 1–11) occurred between 9 January and 20 February in the province of Styria due to one transmission chain with four case generations. Of 31 vaccine-eligible cases, 25 (80.6%) were unvaccinated, of which 13 refused vaccination. Between 10 January and 1 March, we identified 12 cases as part of five unlinked clusters in the province of Salzburg. Each of these five clusters consisted of two generations: the primary case and the successive cases (median age: 22 years, IQR: 11–35). Eleven of 12 cases occurred in unvaccinated patients, with none of the 11 having a vaccination-refusing attitude. An extended measles cluster in a vaccination-refusing community, compared to five short-lived clusters concurrently occurring in the neighboring province, illustrates how vaccine refusal may hamper control of transmission.

A Web Application About Herd Immunity Using Personalized Avatars: Development Study

BACKGROUND

Herd immunity or community immunity refers to the reduced risk of infection among susceptible individuals in a population through the presence and proximity of immune individuals. Recent studies suggest that improving the understanding of community immunity may increase intentions to get vaccinated.

OBJECTIVE

This study aims to design a web application about community immunity and optimize it based on users' cognitive and emotional responses.

METHODS

Our multidisciplinary team developed a web application about community immunity to communicate epidemiological evidence in a personalized way. In our application, people build their own community by creating an avatar representing themselves and 8 other avatars representing people around them, for example, their family or coworkers. The application integrates these avatars in a 2-min visualization showing how different parameters (eg, vaccine coverage, and contact within communities) influence community immunity. We predefined communication goals, created prototype visualizations, and tested four iterative versions of our visualization in a university-based human-computer interaction laboratory and community-based settings (a cafeteria, two shopping malls, and a public library). Data included psychophysiological measures (eye tracking, galvanic skin response, facial emotion recognition, and electroencephalogram) to assess participants' cognitive and affective responses to the visualization and verbal feedback to assess their interpretations of the visualization's content and messaging.

RESULTS

Among 110 participants across all four cycles, 68 (61.8%) were women and 38 (34.5%) were men (4/110, 3.6%; not reported), with a mean age of 38 (SD 17) years. More than half (65/110, 59.0%) of participants reported having a university-level education. Iterative changes across the cycles included adding the ability for users to create their own avatars, specific signals about who was represented by the different avatars, using color and movement to indicate protection or lack of protection from infectious disease, and changes to terminology to ensure clarity for people with varying educational backgrounds. Overall, we observed 3 generalizable findings. First, visualization does indeed appear to be a promising medium for conveying what community immunity is and how it works. Second, by involving multiple users in an iterative design process, it is possible to create a short and simple visualization that clearly conveys a complex topic. Finally, evaluating users' emotional responses during the design process, in addition to their cognitive responses, offers insights that help inform the final design of an intervention.

CONCLUSIONS

Visualization with personalized avatars may help people understand their individual roles in population health. Our app showed promise as a method of communicating the relationship between individual behavior and community health. The next steps will include assessing the effects of the application on risk perception, knowledge, and vaccination intentions in a randomized controlled trial. This study offers a potential road map for designing health communication materials for complex topics such as community immunity.

Preparing for A COVID-19 Vaccine: A Mixed Methods Study of Vaccine Hesitant Parents

This study investigated vaccine acceptance of putative COVID-19 vaccines among a national sample of vaccine hesitant parents. Vaccine hesitancy and politicization of vaccine development has led to a pronounced distrust of COVID-19 vaccines in the U.S. A total of 1,381 vaccine-hesitant parents participated in this study. Participants indicated a general unwillingness to vaccinate their children (M = 3.55, SD = 2.13) and themselves (M = 3.58, SD = 2.16) when a COVID-19 vaccine becomes available. More educated parents were more likely to plan to vaccinate themselves [F(5, 533) = 9.93, p < .05] and their children [F(5, 533) = 10.278, p < .05]. Understanding vaccine hesitant parents offers crucial insights as a COVID-19 vaccine becomes available for the general public and as we wait for a vaccine to be approved for pediatric use.

Influenza vaccination among U.S. pediatric patients receiving care from federally funded health centers

INTRODUCTION

During the 2018-2019 influenza season, vaccination coverage among U.S. children was 62.6%. The purpose of this study was to estimate the prevalence of influenza vaccinations among pediatric patients seen in U.S. health centers, and to explore potential disparities in vaccination coverage among subpopulations. Funded by the Health Resources and Services Administration (HRSA) within the U.S. Department of Health and Human Services, these health centers provide primary and preventive care to underserved and vulnerable individuals and families in order to reduce health disparities based on economic, geographic, or cultural barriers.

METHODS

Cross-sectional data, analyzed in 2019, came from the most recent waves of the Health Center Patient Survey (2009, 2014). The sample consisted of children ages 2-17 years receiving care from HRSA-funded health centers. The outcome of interest was self- or parent-reported receipt of influenza vaccine in the past year. Multivariable logistic regression was used to estimate the adjusted prevalence rate ratios for the association between demographic characteristics (age, sex, race/ethnicity, poverty level, urban/rural residence, geographic region), health-related variables (receipt of well-child check-up, asthma diagnosis), and influenza vaccination.

RESULTS

Influenza vaccination coverage among pediatric health center patients increased from 46.6% in 2009 to 67.8% in 2014. In the adjusted model for 2014, there were few statistically significant differences in vaccination coverage among subpopulation groups, however American Indian/Alaska Native children had 31% increased vaccination coverage compared with non-Hispanic White children (aPRR: 1.31, 95% CI: 1.02-1.60) and children living in the South had 26% decreased vaccination coverage compared with those living in the Northeast (aPRR: 0.74, 95% CI: 0.54-0.93).

CONCLUSIONS

Influenza vaccination coverage among pediatric health center patients in 2014 exceeded the national average (as of 2018-2019), and few differences were found among at-risk subpopulations. HRSA-funded health centers are well-positioned to further increase the vaccination rate among children living in underserved communities.

Unvaccinated children as community parasites in National Qualitative Study from Turkey

Background

This national qualitative study explores (1) the experiences, observations, and opinions of health care workers (HCWs) about beliefs, socioeconomic, cultural, and environmental characteristics of parents refusing vaccination and (2) regional differences in the identified risk factors; (3) recommended solutions to improve vaccine acceptance in each of 12 regions in Turkey.

Methods

In total, we carried out 14 individual semi-structured in-depth interviews and 10 focus group discussions with 163 HCWs from 36 provinces. A thematic analysis was performed to explore HCWs’ observations about the parents’ decisions to reject vaccination and possible solutions for vaccine advocacy.

Results

Within the analyzed data framework, vaccine refusal statements could be defined as vaccine safety, the necessity of vaccines, assumptions of freedom of choice, health workers’ vaccine hesitancy, lack of information about national vaccination schedule and components, not trusting the health system, anti-vaccine publications in social media and newspapers, and refugees. Suggestions based on the HCWs suggestions can be summarized as interventions including (1) creating visual cards with scientific data on vaccine content and disease prevention and using them in counseling patients, (2) writing the vaccine components in a way understandable to ordinary people, (3) highlighting the national quality control and production in the vaccine box and labels, (4) conducting interviews with community opinion leaders, (5) training anti-vaccine HCWs with insufficient scientific knowledge and (6) reducing the tax of parents whose children are fully and punctually vaccinated.

Conclusions

The solution to vaccine rejection begins with the right approaches to vaccination during pregnancy. Prepared written and visual information notes should present the information as “vaccination acceptance” rather than “vaccination refusal”. Further studies on vaccine refusal rates should be carried out in various regions of the world so that region-specific actions are implemented to decrease the anti-vaxxer movement and to prevent an outbreak of infectious diseases.

Vaccine confidence: the keys to restoring trust

During the 20th century, the discovery of modern vaccines and ensuing mass vaccination dramatically decreased the incidence of many infectious diseases and in some cases eliminated them. Despite this, we are now witnessing a decrease in vaccine confidence that threatens to reverse the progress made. Considering the different extents of low vaccine confidence in different countries of the world, both developed and developing, we aim to contribute to the discussion of the reasons for this, and to propose some viable scientific solutions to build or help restore vaccine confidence worldwide.

'When you welcome well, you vaccinate well': a qualitative study on improving vaccination coverage in urban settings in Conakry, Republic of Guinea

BACKGROUND

Recurrent measles outbreaks followed by mass vaccination campaigns (MVCs) occur in urban settings in sub-Saharan countries. An understanding of the reasons for this is needed to improve future vaccination strategies. The 2017 measles outbreak in Guinea provided an opportunity to qualitatively explore suboptimal vaccination coverage within an MVC among participants through their perceptions, experiences and challenges.

METHODS

We conducted focus group discussions with caregivers (n=68) and key informant interviews (n=13) with health professionals and religious and community leaders in Conakry. Data were audio-recorded, transcribed verbatim from Susu and French, coded and thematically analysed.

RESULTS

Vaccinations were widely regarded positively and their preventive benefits noted. Vaccine side effects and the subsequent cost of treatment were commonly reported concerns, with further knowledge requested. Community health workers (CHWs) play a pivotal role in MVCs. Caregivers suggested recruiting CHWs from local neighbourhoods and improving their attitude, knowledge and skills to provide information about vaccinations. Lack of trust in vaccines, CHWs and the healthcare system, particularly after the 2014-2016 Ebola epidemic, were also reported.

CONCLUSIONS

Improving caregivers' knowledge of vaccines, potential side effects and their management are essential to increase MVC coverage in urban settings. Strengthening CHWs' capacities and appropriate recruitment are key to improving trust through a community involvement approach.

A meta-synthesis study of the key elements involved in childhood vaccine hesitancy

OBJECTIVES

Immunization is one of the most successful and cost-effective interventions to improve health outcomes. However, internationally, the phenomenon of parental vaccine hesitancy is increasing and presents a growing challenge for health professionals. This article summarizes the evidence surrounding childhood vaccine hesitancy from the perspective of parents.

STUDY DESIGN

We conducted a systematic review and meta-synthesis of qualitative studies.

METHODS

We searched for qualitative research articles in electronic databases from inception to March 2018. In addition, a manual search of the retrieved articles and their references was conducted to identify other potential articles. We used the Critical Appraisal Skills Programme to examine study validity, adequacy and potential applicability of the results. No articles were excluded for reasons of quality. By performing a meta-synthesis, we identified descriptive themes and, subsequently, the conceptual elements of vaccine hesitancy.

RESULTS

The review included 27 studies involving a total of 1557 parents who were hesitant about vaccinating their child. Five overarching categories were identified: (1) risk conceptualization; (2) mistrust towards vaccine-related institutions, pharmaceutical companies, researchers, health professionals and the information from media; (3) parental alternative health beliefs about childhood immunity, vaccine scheduling and the perceived toxicity of vaccinations; (4) philosophical views on parental responsibility; and (5) parents' information levels about vaccination.

CONCLUSIONS

Healthcare providers need to approach this difficult situation considering that parents desire to do what they feel right for the child. Understanding the core elements of hesitancy will allow health professionals to adopt effective communication and behavioural strategies.

Beliefs around childhood vaccines in the United States: A systematic review

BACKGROUND

While childhood vaccines are safe and effective, some parents remain hesitant to vaccinate their children, which has led to outbreaks of vaccine preventable diseases. The goal of this systematic review was to identify and summarize the range of beliefs around childhood vaccines elicited using open-ended questions, which are better suited for discovering beliefs compared to closed-ended questions.

METHODS

PubMed, Embase, and PsycINFO were searched using keywords for childhood vaccines, decision makers, beliefs, and attitudes to identify studies that collected primary data using a variety of open-ended questions regarding routine childhood vaccine beliefs in the United States. Study designs, population characteristics, vaccine types, and vaccine beliefs were abstracted. We conducted a qualitative analysis to conceptualize beliefs into themes and generated descriptive statistics.

RESULTS

Of 1727 studies identified, 71 were included, focusing largely on parents (including in general, and those who were vaccine hesitant or at risk of hesitancy). Seven themes emerged: Adverse effects was most prominent, followed by mistrust, perceived lack of necessity, pro-vaccine opinions, skepticism about effectiveness, desire for autonomy, and morality concerns. The most commonly described beliefs included that vaccines can cause illnesses; a child's immune system can be overwhelmed if receiving too many vaccines at once; vaccines contain harmful ingredients; younger children are more susceptible to vaccine adverse events; the purpose of vaccines is profit-making; and naturally developed immunity is better than that acquired from vaccines. Nearly a third of the studies exclusively assessed minority populations, and more than half of the studies examined beliefs only regarding HPV vaccine.

CONCLUSIONS

Few studies used open-ended questions to elicit beliefs about vaccines. Many of the studies that did so, focused on HPV vaccine. Concerns about vaccine safety were the most commonly stated beliefs about childhood vaccines, likely because studies were designed to capture barriers and challenges to vaccination.

Qualitative Assessment of Vaccine Hesitancy in Romania

Background and objectives: Health systems all over the world are confronted with an alarming rise of cases in which individuals hesitate, delay, and even refuse vaccination, despite availability of quality vaccine services. In order to mitigate and combat this phenomenon, which are now defined by the World Health Organization (WHO) as vaccine hesitancy (VH), we must first understand the factors that lead to its occurrence in an era characterized by wide access to safe and effective vaccines. To achieve this, we conducted field testing of the Vaccine Hesitancy Scale (VHS), as it was developed by the Strategic Advisory Group of Experts Working Group (SAGE WG), in Cluj-Napoca city, Cluj County, Romania. The scale is designed to quantify VH prevalence in a population, establish which vaccines generate the highest percentage of hesitancy, and allow a qualitative assessment of the individual’s reasons for hesitance. Materials and Methods: We conducted an observational cross-sectional survey, which was comprised of descriptive, analytical, and qualitative elements regarding VH. The necessary sample size was 452 individuals. The VHS and Matrix of Determinants (recommended by SAGE WG) for reasons people gave to justify their hesitance, was interpreted by qualitative thematic analysis (QTA) to ensure the validity and reliability in detecting hesitancy across various cultural settings and permit global comparisons. Results: We found a VH of 30.3% and 11.7% of parents reported refusing to vaccinate their child. Among the VH responders, the varicella vaccine generated 35% hesitancy, measles vaccine 27.7%, Human Papillomavirus (HPV) 24.1%, and mumps vaccine 23.4%, respectively. The QTA values for percent agreement ranged from 91% to 100%. Cohen’s Kappa values ranged from 0.45 to 0.95. Contextual influences identified for VH were “media,” “leaders and lobbies,” and “perception of the pharmaceutical industry.” Individual and group influences for VH were “beliefs,” “knowledge,” and “risk/benefits (perceived).” Vaccine and vaccination specific issues for VH were “risk/benefit (rational)” and “health care practitioners (trustworthiness, competence).” Conclusions: One-third of the investigated population had expressed VH, and a further one-third of these had refused a vaccine for their child. Chicken Pox, Measles, Mumps, Rubella (MMR), and HPV vaccines generated the most hesitation. Negative information from the media was the most frequently evoked reason for VH.

Relative contributions of parental intention and provider recommendation style to HPV and meningococcal vaccine receipt

We described the relative contributions of parental intention and provider recommendation style to HPV and meningococcal vaccine receipt. Parent-child dyads that were eligible for both meningococcal and HPV vaccines participated in pre-visit surveys and consented to audio recording of their clinical interactions with healthcare providers related to vaccination. Surveys were analyzed for parent and child demographics and parental intention to vaccinate children with HPV and/or meningococcal vaccines. Audio recordings were analyzed for provider recommendation style, defined as indicated (provider stated vaccine was due at that visit) or not, and for child receipt of vaccines. Linear and logistic regression models were used to determine the relative contributions of parental intention and provider recommendation style to vaccine receipt. 56 parents/child dyads participated. 79% of children received HPV vaccines, and 93% received meningococcal vaccines. After controlling for demographic variables, parental intention did not differ by vaccine type. However, providers were less likely to use an indicated recommendation for HPV than for meningococcal vaccine. After controlling for demographic factors, parental intention, and provider recommendation style, vaccine type (HPV or meningococcal) was no longer associated with vaccine receipt Differences that were previously attributed to vaccine-specific factors may be explained by parents' and providers' roles in vaccine receipt. These findings suggest that interventions and policy recommendations regarding adolescent vaccination should focus on increasing parental demand for vaccines and ensuring that providers present all vaccines as the medical standard of care.

Development of a measure to assess vaccine confidence among men who have sex with men

BACKGROUND

Recent serogroup C meningococcal disease outbreaks led to meningococcal vaccine recommendations for Southern California men who have sex with men (MSM). Assessment of vaccine confidence is critical to improving vaccine coverage in the context of disease outbreaks wherein immunization(s) are recommended.

METHODS

We surveyed MSM using venue-based sampling and began development of the vaccine confidence index (VCI) with 30 survey items corresponding to trust- and safety-related perceptions. We performed exploratory factor analyses and computed the Cronbach's alpha coefficient to assess internal consistency of the VCI. We created a categorical confidence variable (low, medium, and high confidence) and conducted bivariate and multivariate analyses to evaluate associations with reported confidence and immunization uptake.

RESULTS

Ten survey items were included in the final VCI and formed the confidence measure. Participants with low confidence had the lowest levels of reported uptake for both meningococcal vaccines. Confidence differed significantly (p ≤ 0.05) between MSM who indicated they received vaccines recommended within the context of the outbreak and those who did not.

CONCLUSIONS

Our VCI is sensitive to a number of issues that may influence vaccine confidence. It is useful for assessing MSM trust and acceptance of recommended immunizations and may be used to inform intervention development.

Acceptability of the dengue vaccination among parents in urban poor communities of Quezon City, Philippines before and after vaccine suspension

Objective

The study aims to illustrate the acceptability of the dengue vaccine before and after the dengue vaccination suspension in urban poor communities in Quezon City, Philippines.

Results

There were 12 interviews conducted in November 2017 and 5 focus group discussions in January 2018, a month after vaccine program suspension with 41 participants. All participants were selected through purposive criterion sampling. Thematic analysis showed acceptability of the dengue vaccine was associated with parental experience with vaccination and dengue, trust in public health institutions and communication received by parents. Post-dengue vaccination suspension triangulation indicated that the parents regretted the experience, trust to public institutions was eroded and the communication strategy was deemed inadequate. This led to low vaccine acceptability post-vaccine suspension.