German travelers' preferences for travel vaccines assessed by a discrete choice experiment

Pre-travel vaccine information needs, attitudes, drivers of uptake and the role for decision aids in travel medicine

BACKGROUND

Many travellers do not receive vaccines pre-travel. Tools such as vaccine decision aids could support informed vaccine decision-making. We aimed to characterise Australians' pre-travel vaccine attitudes, behaviours and information needs and examine the role for decision aids in travel medicine.

METHODS

Online cross-sectional survey of Australian adults in December 2022. We included questions on demographics, pre-travel health-seeking behaviour, and information needs. We measured vaccine confidence (Vaccine Confidence Index Index) and used hypothetical disease scenarios to evaluate behavioural and social drivers of vaccination. We used multivariable logistic regression models to identify predictors of vaccine uptake and thematically analysed free-text responses.

RESULTS

We received complete survey responses from 1223/1326 Australians (92% response rate). Amongst those reporting previous overseas travel, 67% (778/1161) reported past pre-travel health encounter(s) and 64% (743/1161) reported past pre-travel vaccination. Half (50%) strongly agreed that vaccines were important for their health; fewer strongly agreed that vaccines were safe (37%) and effective (38%). In multivariable analyses, past pre-travel vaccine uptake was associated with increasing age (OR = 1.17 [95% CI 1.08-1.27] p < 0.001 per ten-year increase) and travel to higher-risk destinations (OR = 2.92 [2.17-3.93] p < 0.001); travellers visiting friends and relatives (VFRs) were less likely to have received pre-travel vaccines (OR = 0.74 [0.56-0.97] p = 0.028). Predictors for wanting vaccination against hypothetical diseases included past pre-travel vaccination (Disease X: OR 2.60 [1.91-3.56] p < 0.001) and confidence in vaccine safety (Disease X: OR 7.18 [5.07-10.18], p < 0.001); past VFR travel was predictive of not wanting vaccination (Disease X: OR 0.72 [0.52-1.00], p = 0.049). Most (63%) were interested in using a vaccine decision aid, generally together with a trusted health professional.

CONCLUSIONS

Health professionals play an important role in supporting pre-travel vaccine decision-making. However, our findings indicate that reliable, accurate and engaging digital resources, such as decision aids, could support travellers to make informed pre-travel vaccine decisions.

Living with HIV and Getting Vaccinated: A Narrative Review

After 40 years of its appearance, human immunodeficiency virus (HIV) infection remains a leading public health challenge worldwide. Since the introduction of antiretroviral treatment (ART), HIV infection has become a chronic condition, and people living with HIV could have life expectancies close to those of the general population. People with HIV often have an increased risk of infection or experience more severe morbidity following exposure to vaccine-preventable diseases. Nowadays, several vaccines are available against bacteria and viruses. However, national and international vaccination guidelines for people with HIV are heterogeneous, and not every vaccine is included. For these reasons, we aimed to perform a narrative review about the vaccinations available for adults living with HIV, reporting the most updated studies performed for each vaccine among this population. We performed a comprehensive literature search through electronic databases (Pubmed-MEDLINE and Embase) and search engines (Google Scholar). We included English peer-reviewed publications (articles and reviews) on HIV and vaccination. Despite widespread use and guideline recommendations, few vaccine trials have been conducted in people with HIV. In addition, not all vaccines are recommended for people with HIV, especially for those with low CD4 cells count. Clinicians should carefully collect the history of vaccinations and patients' acceptance and preferences and regularly check the presence of antibodies for vaccine-preventable pathogens.

Patient Preferences for Pharmaceutical and Device-Based Treatments for Uncontrolled Hypertension: Discrete Choice Experiment

BACKGROUND

Discrete choice experiment is a survey method used to understand how individuals make decisions and to quantify the relative importance of features. Using discrete choice experiment methods, we quantified patient benefit-risk preferences for hypertension treatments, including pharmaceutical and interventional treatments, like renal denervation.

METHODS

Respondents from the United States with physician-confirmed uncontrolled hypertension selected between treatments involving a procedure or pills, using a structured survey. Treatment features included interventional, noninterventional, or no hypertension treatment; number of daily blood pressure (BP) pills; expected reduction in office systolic BP; duration of effect; and risks of drug side effects, access site pain, or vascular injury. The results of a random-parameters logit model were used to estimate the importance of each treatment attribute.

RESULTS

Among 400 patients completing the survey between 2020 and 2021, demographics included: 52% women, mean age 59.2±13.0 years, systolic BP 155.1±12.3 mm Hg, and 1.8±0.9 prescribed antihypertensive medications. Reduction in office systolic BP was the most important treatment attribute. The remaining attributes, in decreasing order, were duration of effect, whether treatment was interventional, number of daily pills, risk of vascular injury, and risk of drug side effects. Risk of access site pain did not influence choice. In general, respondents preferred noninterventional over interventional treatments, yet only a 2.3 mm Hg reduction in office systolic BP was required to offset this preference. Small reductions in office systolic BP would offset risks of vascular injury or drug side effects. At least a 20% risk of vascular injury or drug side effects would be tolerated in exchange for improved BP.

CONCLUSIONS

Reduction in systolic BP was identified as the most important driver of patient treatment preference, while treatment-related risks had less influence. The results indicate that respondents would accept interventional treatments in exchange for modest reductions in systolic BP compared with those observed in renal denervation trials.

COVID-19-Induced Redundancy and Socio-Psychological Well-Being of Tourism Employees: Implications for Organizational Recovery in a Resource-Scarce Context

Drawing on social and psychological well-being literature underpinned by the concept of resilience, this study examines the impact of COVID-19 induced redundancy on the socio-psychological well-being of redundant employees (laid-off or working reduced hours), and its effect on their commitment to work and support recovery in the tourism industry. Utilizing a quantitative-dominant mixed methods design, 457 questionnaires were administered, and 15 interviews conducted with redundant employees in Ghana between May and August 2020. Results from a binary logistic regression analysis of the survey data supported by qualitative interview analysis indicate that marital status, education, status of dependents, and the types of tourism businesses employed in, significantly influenced psychological well-being while marital status, age, education, and rank in the organization influenced the social well-being of respondents. Meanwhile, psychological well-being significantly influenced future work commitment in the industry. Managerial implications for supporting employee resilience, well-being, and future recovery strategies are critically examined.

Parental preference for Haemophilus influenzae type b vaccination in Zhejiang Province, China: A discrete choice experiment

Background

China is the only country in the world that has not included the Haemophilus influenzae type b (Hib) vaccine in its National Immunization Program, making it more difficult to eliminate Hib-related diseases through Hib vaccination. It is necessary to study parental preferences for Hib vaccination to optimize vaccine promotion strategies in China.

Objective

This study aimed to investigate Chinese parental preference for five attributes of Hib vaccination, i.e., the place of origin, effectiveness, adverse event, doctors' recommendation, and the price of full vaccination when making a decision to vaccinate their children under 2 years old.

Methods

A cross-sectional survey was conducted in two cities in Zhejiang Province from November to December in 2020 using a discrete choice experiment (DCE). A mixed logit model was used to estimate participating parents' preference for Hib vaccination attributes included in the DCE. Subgroup analysis and probability analysis were also conducted to capture the heterogeneity and trade-off of parental preference for Hib vaccination.

Results

Data from 6,168 observations were included in the analyses. Parents of children are, on average, more likely to voice a positive preference for Hib vaccination. Such attributes of Hib vaccination as effectiveness and doctor's recommendation have a significant positive influence on parents' preference for Hib vaccination, while imported vaccines, adverse events, and the price of full vaccination have a significant negative influence on parents' preference. Parents with different demographic characteristics also existed heterogeneities in preference for Hib vaccination. Parents will make a trade-off on price if the Hib vaccine has a good performance on effectiveness and safety.

Conclusion

The study found that, regardless of the place of origin of the Hib vaccine, parents with children under 2 years old prefer to compromise on price if the vaccine has a better effectiveness and safety profile. A proactive recommendation from doctors would strengthen their willingness for Hib vaccination. These findings help aid the development of communication strategies with parents for Hib vaccination in China.

Travelers' preferences for tick-borne encephalitis vaccination

BACKGROUND

This study aimed to quantify preferences and risk tolerance for a tick-borne encephalitis (TBE) vaccination.

RESEARCH DESIGN AND METHODS

A stated-preference survey instrument was administered to international travelers living in the United States to elicit preferences for a no-cost TBE vaccine when planning an international trip, conditional upon four different qualitative levels of endemic TBE risk.

RESULTS

The likelihood of choosing the vaccine increased with a destination's level of endemic risk. Most respondents (94%) would choose to receive the vaccine at the highest risk level presented in the survey (i.e. when multiple TBE cases among humans are reported year after year); 6% of the sample would choose not to receive the vaccine at any risk level. Respondents who engage in outdoor activities were twice as likely as the average respondent to choose vaccination rather than opting out of vaccination, and were one-third more likely than the average respondent to choose to receive the vaccine at the lowest risk level.

CONCLUSIONS

Respondents were highly interested in a TBE vaccine, assuming no cost, and most were willing to be vaccinated at all qualitative TBE risk levels. Respondents who participated in outdoor activities were more likely than the average respondent to choose the vaccine.

You Only Live Once! Understanding Indonesian and Taiwan Travel Intention During COVID-19 Pandemic

Indonesia and Taiwan are two countries that have been affected by the tourism sector, although with different policies to control the COVID-19 pandemic. Taiwan is known as a country with pandemic policies that have been recognized around the world, although it has a high vulnerability to experiencing a high number of infections due to its geographical and political position close to the source of the pandemic. On the other hand, Indonesia is known for its controversial pandemic management and control policies. Indonesia and Taiwan have carried out various public policies to increase tourism activities during the pandemic, such as accelerating vaccination in tourist areas and for tourists, as well as various other stimuli to stimulate tourism. The debate over vaccination raises questions about attitudes toward vaccines in society. The lack of clarity on psychosocial and political conditions creates confusion among the public in perceiving the COVID-19 pandemic and in perceiving the risks of traveling. This can affect people's attitudes toward vaccines, travel anxiety, and travel intentions. This study aims to analyze traveling intention due to the COVID-19 pandemic through COVID-19 Risk Perception, Fear of COVID-19, Risk Perception to Travel, Vaccine Attitude, and Fear to Travel. The research in Indonesia involved 358 respondents while the research in Taiwan involved 283 respondents. The research analysis used multiple regression and simple linear regression to ascertain the role of each association. The results showed that the travel intention of Indonesian tourists was formed from the direct and indirect roles of covid 19 risk perception, fear of covid 19, risk perception to travel, vaccine attitude, and fear to travel. Meanwhile, the travel intention of Taiwanese tourists is not influenced by a fear of covid. The travel intention model of Taiwanese tourists is formed from the direct and indirect roles of covid 19 risk perception, risk perception to travel, vaccine attitude, and fear to travel. This research contributes to tourism risk management in the face of pandemics, particularly in terms of government policies that can reduce tourism anxiety to travel during disasters.

Using social media listening and data mining to understand travellers' perspectives on travel disease risks and vaccine-related attitudes and behaviours

BACKGROUND

Travellers can access online information to research and plan their expeditions/excursions, and seek travel-related health information. We explored German travellers' attitude and behaviour toward vaccination, and their travel-related health information seeking activities.

METHODS

We used two approaches: web 'scraping' of comments on German travel-related sites and an online survey. 'Scraping' of travel-related sites was undertaken using keywords/synonyms to identify vaccine- and disease-related posts. The raw unstructured text extracted from online comments was converted to a structured dataset using Natural Language Processing Techniques. Traveller personas were defined using K-means based on the online survey results, with cluster (i.e. persona) descriptions made from the most discriminant features in a distinguished set of observations. The web-scraped profiles were mapped to the personas identified. Travel and vaccine-related behaviours were described for each persona.

RESULTS

We identified ~2.6 million comments; ~880 k were unique and mentioned ~280 k unique trips by ~65 k unique profiles. Most comments were on destinations in Europe (37%), Africa (21%), Southeast Asia (12%) and the Middle East (11%). Eight personas were identified: 'middle-class family woman', 'young woman travelling with partner', 'female globe-trotter', 'upper-class active man', 'single male traveller', 'retired traveller', 'young backpacker', and 'visiting friends and relatives'. Purpose of travel was leisure in 82-94% of profiles, except the 'visiting friends and relatives' persona. Malaria and rabies were the most commented diseases with 12.7 k and 6.6 k comments, respectively. The 'middle-class family woman' and the 'upper-class active man' personas were the most active in online conversations regarding endemic disease and vaccine-related topics, representing 40% and 19% of comments, respectively. Vaccination rates were 54%-71% across the traveller personas in the online survey. Reasons for vaccination reluctance included perception of low risk to disease exposure (21%), price (14%), fear of side effects (12%) and number of vaccines (11%).

CONCLUSIONS

The information collated on German traveller personas and behaviours toward vaccinations should help guide counselling by healthcare professionals.

Exploring patient preference heterogeneity for pharmacological treatments for chronic pain: A latent class analysis

BACKGROUND

Several pharmaceutical treatments for chronic pain caused by osteoarthritis (OA) and chronic low back pain (CLBP) are available or currently under development, each associated with different adverse events (AEs) and efficacy profiles. It is therefore important to understand what trade-offs patients are willing to make when choosing between treatments.

METHODS

A discrete-choice experiment (DCE) was conducted with 437 adults with chronic pain caused by OA and/or CLBP. Respondents were presented with a series of scenarios and asked to choose between pairs of hypothetical treatments, each defined by six attributes: level of symptom control; risks of heart attack, rapidly progressive osteoarthritis and dependency; frequency and mode of administration and cost. Attributes were based on known profiles of oral nonsteroidal anti-inflammatory drugs, opioids and injected nerve growth factor inhibitors, the last of which were under clinical development at the time of the study. Data were analysed using a latent class (LC) model to explore preference heterogeneity.

RESULTS

Overall, respondents considered improving symptom control and reducing risk of physical dependency to be the most important attributes. The LC analysis identified four participant classes: an 'efficacy-focused' class (33.7%), a 'cost-averse' class (29.4%), a 'physical-dependence-averse' class (19.6%) and a 'needle-averse' class (17.3%). Subgroup membership was incompletely predicted by participant age and their responses to comprehension questions.

CONCLUSIONS

Preference heterogeneity across respondents indicates a need for a personalized approach to offering treatment options. Symptom improvement, cost, physical dependence and route of administration might be important to different patients.

SIGNIFICANCE

Multiple treatment options that differ substantially in terms of efficacy and adverse events are available for the management of chronic pain. With a growing emphasis on a patient-centred care model that incorporates patients' priorities and values into treatment decisions, there is a need to understand how individuals with chronic musculoskeletal pain balance the benefits and risks of treatment and how treatment priorities vary among individuals. This study was designed to identify patient preferences for different characteristics of treatments for the management of chronic pain and to investigate how preferences differ among respondents.

Vaccine preferences driving vaccine-decision making of different target groups: a systematic review of choice-based experiments

BACKGROUND

Choice-based experiments have been increasingly used to elicit preferences for vaccines and vaccination programs. This study aims to systematically identify and examine choice-based experiments assessing (differences in) vaccine preferences of vaccinees, representatives and health advisors.

METHODS

Five electronic databases were searched on choice-based conjoint analysis studies or discrete choice experiments capturing vaccine preferences of children, adolescents, parents, adults and healthcare professionals for attributes of vaccines or vaccine settings up to September 2020. Data was extracted using a standardized form covering all important aspects of choice experiments. A quality assessment was used to assess the validity of studies. Attributes were categorized into outcome, process, cost and other. The importance of attributes was assessed by the frequency of reporting and statistical significance. Results were compared between high-quality studies and lower-quality studies.

RESULTS

A total of 42 studies were included, with the majority conducted in high-income countries after 2010 (resp. n = 34 and n = 37). Preferences of representatives were studied in nearly half of the studies (47.6%), followed by vaccinees (35.7%) and health advisors (9.5%). Sixteen high-quality studies passed the quality assessment. Outcome- and cost- related attributes such as vaccine effectiveness, vaccine risk, cost and protection duration were most often statistically significant across both target groups, with vaccine effectiveness being the most important. Risks associated with vaccination, such as side effects, were more often statistically significant in studies targeting vaccinees, while cost-related attributes were more often statistically significant in studies of representatives. Process-related attributes such as vaccine accessibility and time were least important across both target groups.

CONCLUSION

To our knowledge, this is the first systematic review in which vaccine preferences of different target groups were assessed and compared. The same attributes were most important for vaccine decisions of vaccinees and representatives, with only minor differences in level of evidence for vaccine risk and cost. Future research on vaccine preferences of health advisors and/or among target groups in low-resource settings would give insight into the generalizability of current findings.

Preferences for herpes zoster vaccination among adults aged 50 years and older in the United States: results from a discrete choice experiment

BACKGROUND

Most adults, and disproportionately fewer African-Americans, have not received herpes zoster (HZ) vaccination despite current recommendations. This study (GSK study identifiers: 208677/HO-17-18066) assessed HZ vaccination preferences among adults aged ≥ 50 years.

RESEARCH DESIGN AND METHODS

In this discrete choice experiment, respondents chose among a 'no vaccine' option and two HZ vaccine profiles, characterized by seven attributes, in a series of choice questions. Random-parameters logit results were used to predict likely vaccine uptake. Subgroup and latent class analysis of African-American's preferences were performed.

RESULTS

The preference weight for choosing HZ vaccines over no vaccine was statistically significant among the 1,454 respondents (71.9% whites; 25.2% African-Americans). Out-of-pocket (OOP) cost and vaccine effectiveness (VE) were the most important attributes. The African-American and the non-African-American subgroups had statistically significant differences in preferences (χ² = 59.91, p < 0.001), mainly driven by OOP cost and VE. Latent class analysis identified three groups of African-American respondents with systematically different preferences; two comprised likely-vaccinators, with one being more cost sensitive at lower price thresholds, and one likely non-vaccinators.

CONCLUSIONS

For all respondents, HZ vaccine choices were most sensitive to total OOP cost, followed by VE.

Beyond fragmentary: A proposed measure for travel vaccination concerns

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

No Such Thing as a Free-Rider? Understanding Drivers of Childhood and Adult Vaccination through a Multicountry Discrete Choice Experiment

Increased vaccine hesitancy and refusal negatively affects vaccine uptake, leading to the reemergence of vaccine preventable diseases. We aim to quantify the relative importance of factors people consider when making vaccine decisions for themselves, or for their child, with specific attention for underlying motives arising from context, such as required effort (accessibility) and opportunism (free riding on herd immunity). We documented attitudes towards vaccination and performed a discrete choice experiment in 4802 respondents in The United Kingdom, France and Belgium, eliciting preferences for six attributes: (1) vaccine effectiveness, (2) vaccine preventable disease burden, (3) vaccine accessibility in terms of copayment, vaccinator and administrative requirements, (4) frequency of mild vaccine-related side-effects, (5) vaccination coverage in the country’s population and (6) local vaccination coverage in personal networks. We distinguished adults deciding on vaccination for themselves from parents deciding for their youngest child. While all attributes were found to be significant, vaccine effectiveness and accessibility stood out in all (sub)samples, followed by vaccine preventable disease burden. We confirmed that people attach more value to severity of disease compared to its frequency, and discovered that peer influence dominates free-rider motives, especially for the vaccination of children. These behavioral data are insightful for policy and are essential to parameterize dynamic vaccination behavior in simulation models. In contrast to what most game theoretical models assume, social norms dominate free-rider incentives. Policy-makers and healthcare workers should actively communicate on high vaccination coverage, and draw attention to the effectiveness of vaccines while optimizing their practical accessibility.

Parental Vaccine Preferences for Their Children in China: A Discrete Choice Experiment

Vaccination is one of the most cost-effective health investments to prevent and control communicable diseases. Improving the vaccination rate of children is important for all nations, and for China in particular since the advent of the two-child policy. This study aims to elicit the stated preference of parents for vaccination following recent vaccine-related incidents in China. Potential preference heterogeneity was also explored among respondents. Methods: A discrete choice experiment was developed to elicit parental preferences regarding the key features of vaccines in 2019. The study recruited a national sample of parents from 10 provinces who had at least one child aged between 6 months and 5 years old. A conditional logit model and a mixed logit model were used to estimate parental preference. Results: A total of 598 parents completed the questionnaire; among them, 428 respondents who passed the rational tests were analyzed. All attributes except for the severity of diseases prevented by vaccines were statistically significant. The risk of severe side effects and protection rates were the two most important factors explaining parents’ decisions about vaccination. The results of the mixed logit model with interactions indicate that fathers or rural parents were more likely to vaccinate their children, and children whose health was not good were also more likely to be vaccinated. In addition, parents who were not more than 30 years old had a stronger preference for efficiency, and well-educated parents preferred imported vaccines with the lowest risk of severe side effects. Conclusion: When deciding about vaccinations for their children, parents in China are mostly driven by vaccination safety and vaccine effectiveness and were not affected by the severity of diseases. These findings will be useful for increasing the acceptability of vaccination in China.

Attributes influencing parental decision-making to receive the Tdap vaccine to reduce the risk of pertussis transmission to their newborn - outcome of a cross-sectional conjoint experiment in Spain and Italy

Pertussis vaccination of parents and household contacts (‘cocooning’) to protect newborn infants is an established strategy in many countries, although uptake may be low. Many aspects may influence such decision-making. We conducted a cross-sectional survey (NCT01890447) of households and other close contacts of newborns aged ≤6 months (or of expectant mothers in their last trimester) in Spain and Italy, using an adaptive discrete-choice experiment questionnaire. Aims were to assess the relative importance of attributes influencing vaccine adoption, and to estimate variation in vaccine adoption rates and the impact of cost on vaccination rates. Six hundred and fifteen participants (Spain, n = 313; Italy, n = 302) completed the survey. Of 144 available questionnaire scenarios, the most frequently selected (14% of respondents in both countries) were infant protection by household vaccination at vaccination center, recommendation by family physician and health authorities, with information available on leaflets and websites. The attribute with highest median relative importance was ‘reduction in source of infection’ in Spain (23.1%) and ‘vaccination location’ in Italy (18.8%). Differences between other attributes were low in both countries, with media attributes showing low importance. Over 80% of respondents indicated a definite or probable response to vaccine adoption (at no-cost) with estimated probability of adoption of 89–98%; applying vaccine costs (25€ per person) would reduce the probability of uptake by 7–20% in definite/probable respondents. Awareness of these determinants is helpful in informing Health Authorities and healthcare practitioners implementing a cocooning strategy for those populations where maternal immunization is not a preferred option.