Knowledge, attitudes and beliefs towards compulsory vaccination: a systematic review

Mapping Adult Vaccine Confidence in Future Health Professionals: A Pilot Study among Undergraduate Students at Two Universities in Greece

Health professionals' recommendations increase vaccine uptake. We aimed to document stances, practices regarding adult vaccination, and their predictors among undergraduate medical and biomedical science students, as well as their perspectives on increasing vaccine confidence. Among the 430 participants, third-year students from two universities in Greece, only 25.4% were in favor of all vaccines, while no refuters were detected. Predictors of recommending vaccination were the Attitudes Towards Adult Vaccination (ATAVAC) Value (OR 3.26, p < 0.001) and ATAVAC Safety subscales scores (OR 1.36, p < 0.05), being a medical student (OR 2.45, p < 0.05), and having better self-rated health status (OR 2.27, p < 0.05). The importance of getting vaccinated as health professionals was recognized by participants with a higher ATAVAC value (OR 5.39, p < 0.001), ATAVAC Safety scores (OR 1.46, p < 0.05), and increased knowledge regarding the National Immunization Program (OR 1.31, p < 0.05). The God Locus of Health Control (GLHC) was a predictor only in vaccination against COVID-19 (OR 0.91, p < 0.05). Improving community health literacy and health providers' education, boosting trust in authorities, and adopting a person-centered approach emerged as the main themes regarding how to increase vaccine confidence. Mapping health professionals' confidence in vaccines and providing lifelong training support is pivotal in supporting positive attitudes, enhancing their competence, and promoting vaccination in the post-COVID-19 era.

Dark side of the principles of non-discrimination and proportionality: the case of mandatory vaccination

Deciding the conflict between various rights and interests, especially in medical ethics where health and lives are in question, has significant challenges, and to obtain appropriate outcomes, it is necessary to properly apply the principles of non-discrimination and proportionality. Using the example of mandatory vaccination policies, we show that this task becomes even more difficult when these principles lead us to counterintuitive and paradoxical results. Although the general purpose of these principles is to ensure that decisions and policies seek the highest and broadest possible enjoyment of rights for all (ie, the least restrictive solution), they achieve the complete opposite when applied to mandatory vaccination policies. To highlight and explain these paradoxical results, we present a typology of fifteen hypothetical mandatory vaccination policies containing various degrees of restriction and apply well-established non-discrimination and proportionality tests from constitutional law to each. We argue that mandatory vaccination policies exhibit two characteristics, namely the non-linear relationship between their general purposes and specific goals and the involvement of life and health, suggesting that more restrictive policies should prevail even though less restrictive policies might fail these tests. Using clearly structured and rigorous methodology from constitutional law, the proposed approach delivers a fresh view on the core ethical principles of non-discrimination and proportionality and a potentially useful tool in helping resolve also other challenges encountered in medical ethics beyond mandatory vaccination policies.

Vaccination and the risk of systemic lupus erythematosus: a meta-analysis of observational studies

OBJECTIVE

This meta-analysis aims to explore the potential link between vaccines and systemic lupus erythematosus (SLE).

METHODS

We systematically searched PubMed, Cochrane Library, and Embase for observational studies from inception to September 3, 2023, using medical subject headings (MeSH) and keywords. Study quality was assessed using the NOS scale. Statistical analyses were conducted using STATA software (version 14.0). Publication bias was evaluated using funnel plots and Egger's regression.

RESULTS

The meta-analysis incorporated 17 studies, encompassing 45,067,349 individuals with follow-up periods ranging from 0.5 to 2 years. The pooled analysis revealed no significant association between vaccinations and an increased risk of SLE [OR = 1.14, 95% CI (0.86-1.52), I2 = 78.1%, P = 0.348]. Subgroup analyses indicated that HBV vaccination was significantly associated with an elevated risk of SLE [OR =2.11, 95% CI (1.11-4.00), I2 = 63.3%, P = 0.02], HPV vaccination was slightly associated with an increased risk of SLE [OR = 1.43, 95% CI (0.88-2.31), I2 = 72.4%, P = 0.148], influenza vaccination showed no association with an increased risk of SLE [OR = 0.96, 95% CI (0.82-1.12), I2 = 0.0%, P = 0.559], and COVID-19 vaccine was marginally associated with a decreased risk of SLE [OR = 0.44, 95% CI (0.18-1.21), I2 = 91.3%, P = 0.118].

CONCLUSIONS

This study suggests that vaccinations are not linked to an increased risk of SLE. Our meta-analysis results provide valuable insights, alleviating concerns about SLE risk post-vaccination and supporting further vaccine development efforts.

Exploring Perceptions and Practices Regarding Adult Vaccination against Seasonal Influenza, Tetanus, Pneumococcal Disease, Herpes Zoster and COVID-19: A Mixed-Methods Study in Greece

We aimed to document vaccination coverage for five vaccines, predictors of each vaccine's uptake and attitudes regarding adult vaccination. Adults visiting four pharmacies were randomly invited to participate during summer 2022. Among 395 participants (mean age 51.2 years, range 19-96), vaccination rates were 78.1% for influenza and 25.8% for herpes zoster (≥60 years old), 64.3% for pneumococcal disease (≥65 years old), 33.1% for tetanus, while 11.4% had received two and 74.8% ≥3 COVID-19 vaccine doses. Half of participants (50.1%) voiced some degree of hesitancy, and 1.3% were refusers. The strongest predictor of each vaccine's uptake was doctor's recommendation (OR range 11.33-37.66, p < 0.001) and pharmacist's recommendation (4.01-19.52, p < 0.05), except for the COVID-19 vaccine, where the Attitude Towards Adult VACcination (ATAVAC) value of adult vaccination subscale's score was the only predictor (OR: 5.75, p < 0.001). Regarding insufficient coverage, thematic content analysis revealed seven main themes. Insufficient knowledge, the absence of health professionals' recommendation, perception of low susceptibility to disease, negligence and dispute of vaccine effectiveness were universal themes, whereas safety concerns and distrust in authorities were reported solely for COVID-19 vaccination. Designing public interventions aiming to increase trust in adult vaccination is essential in the aftermath of the COVID-19 pandemic. Health professionals' role in recommending strongly adult vaccination is crucial.

Challenges of hesitancy in human papillomavirus vaccination: Bibliometric and visual analysis

BACKGROUND

Human papillomavirus (HPV) vaccine has immense research value in the prevention of related tumours. A huge body of work has been published in this field, which may pose difficulties for researchers aiming to investigate all the available information. However, bibliometrics can provide deep insights into this research field.

OBJECTIVE

We aimed to study HPV vaccine development, visually analyse the development status, trends, research hotspots, and frontiers of this field, and provide a reference for research on it.

METHODS

Articles were acquired from the Web of Science Core Collection. VOS viewer and CiteSpace software were used to analyse publication growth, country/region, institution, journal distribution, author, reference, and keywords, and collected burst keyword words to display research hotspots.

RESULTS

A total of 4831 references were obtained, and the annual number of publications increased fluctuating over the past decade. The United States of America ranked at the top in terms of percentage of articles. The institution with the highest number of research publications in this field was the Centers for Disease Control and Prevention. The most productive and frequently cited authors was Lauri E Markowitz. The journal with the most publications in this field was Vaccine, and the most influential journal was Paediatrics. The most frequently cited reference was 'A 9-Valent HPV Vaccine against Infection and Intraepithelial Neoplasia in Women'. Burst detection analysis of top keywords showed that 'national immunisation survey', 'social media', and 'hesitancy' are the current research frontiers in this field.

CONCLUSION

This study provides useful information for acquiring knowledge on HPV vaccine. Research on solving the hesitation of HPV vaccination will become an academic trend in this field, which can offer guidance for more extensive and in-depth studies in the future.

Vaccination programs for children aged up to 18 years in Europe, 2020

Although all European countries have vaccination policies for children, there are no comprehensive studies of pediatric vaccination programs in Europe. We studied vaccination programs for children in Europe. Vaccinations against diphtheria, tetanus, pertussis, poliomyelitis, Haemophilus influenzae type b, hepatitis B, measles, mumps, rubella, and influenza existed in 42 countries, against human papilloma virus in 41 countries, and against pneumococcus in 40 countries. In addition, the following vaccinations existed: against tuberculosis (35 countries), hepatitis A (33), meningococcus A, C, W, Y (30), rotavirus and varicella (28 countries each), meningococcus B (24), tick-born encephalitis (22), and meningococcus C (16). Mandatory vaccinations are implemented in 21 countries, mainly against diphtheria, tetanus, pertussis, poliomyelitis, H. influenzae type b, hepatitis B, measles, mumps, rubella, tuberculosis, and pneumococcus. There are significant differences among pediatric vaccination programs in Europe regarding number, schedules, indications, and regulatory frame (recommended or mandatory vaccinations). A consensus-based vaccination program for all children is needed.

Factors associated with pentavalent vaccine coverage among 12-23-month-old children in Afghanistan: A cross-sectional study

INTRODUCTION

This study aimed to identify the factors associated with the coverage of the third dose of pentavalent vaccine (Penta3) among children aged 12-23 months in Afghanistan.

METHODS

The data of 3,040 children aged 12-23 months were taken from the Afghanistan Health Survey 2018, including characteristics of the children and their households, household heads, and mothers/primary care givers. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were estimated using a logistic model. Multivariable stepwise logistic regression analysis with forward-selection (Model 1) and backward-selection (Model 2) was performed using variables that showed significant differences by bivariate analysis.

RESULTS

The coverage of Penta3 among 12-23-month-old children was 82.3%. Factors associated with Penta3 coverage in the two models of multivariable analysis were 18-23 months old compared to 12-17 months old; having no diarrhea in the last two weeks compared to having diarrhea; no bipedal edema compared to having edema; taking vitamin A supplement; 1-2 children under five years in a household compared to three or more; distance from residence to the nearest health facility ≤2 hours on foot; having a radio; having a TV; educated heads of households; non-smoking of heads of households; and literacy of mothers/primary caregivers.

CONCLUSIONS

Penta3 coverage among 12-23-month-old children improved but was still lower than the target. Primary education should be provided to all children throughout the country. TV and radio are useful tools for providing health information. Mobile outreach programs and the establishment of new health facilities should be promoted to improve access to health service for all people in Afghanistan.

Communicating effectively with patients about vaccination: A systematic review of randomized controlled trials

Background

Good communication between healthcare professionals and their patients is essential to enlighten the benefits and risks of vaccination. Despite the availability of effective vaccines, reluctance prevails, sometimes fuelled by sub-optimal communication leading to a lack of trust. An evaluation of the effectiveness of a communication strategy for which healthcare professionals are trained has yet to be carried out.

Objective

Systematic review of studies with a randomized controlled trial (RCT) to define and evaluate the impact of healthcare professionals' communication on patients' vaccine adherence.

Methods

We performed a structured search on Medline, Embase, CENTRAL, PsycINFO and CINAHL. The studies selected include those involving healthcare professionals authorized to administer vaccines according to Canadian guidelines. Primary outcomes include vaccination rate or vaccine hesitancy rate.

Results

Nine articles were included. Five studies (n=5) reported intervention effectiveness according to vaccine adherence. The results are largely represented by parental vaccine hesitancy for human papillomavirus (HPV) or childhood vaccination, while three studies (n=3) target the general population. The risk of bias relative to the studies is either low (n=7) or of some concern (n=2).

Conclusion

The effectiveness of communication varies according to the studies and knowledge acquired through training. Future studies will need to examine communication with healthcare professionals in order to establish a consensus on optimal and appropriate training.

Portrait of French-speaking minorities with respect to vaccination against COVID-19

Background

The coronavirus disease 2019 (COVID-19) vaccination campaign highlighted the requirement to better understand the needs of different populations. French-speaking minorities (FSMs) have greater difficulty accessing quality care in French, and this problem was exacerbated during the COVID-19 pandemic.

Objective

The aim of this survey was to develop a descriptive portrait of the health needs of FSMs in relation to the COVID-19 vaccination campaign by describing their vaccination status, attitudes and beliefs compared with English-speaking majorities.

Methods

A survey was conducted among eligible participants using convenience sampling. Data measurement includes a descriptive statistical comparison using analysis of the variance, univariate logistic regressions and a two-proportions z-test.

Results

Of the 1,505 respondents (554 FSMs vs. 951 English speakers), the FSMs have an average age of 51.4 years and 89.2% are Canadian citizens. Vaccination of children was preponderant among English speakers (74.2% vs. 86.3%), including against COVID-19 (58.6% vs. 73.9%). A higher proportion of FSMs had gotten vaccinated in order to obtain a vaccine passport (39% vs. 29.3%). Among the unvaccinated, FSMs were more likely to question the efficacy of vaccines (60% vs. 36.4%). Canadian citizen FSMs with higher education could be divided in relation to the vaccine regimen.

Conclusion

This survey revealed differences between FSMs and the English-speaking majority in their perceptions of vaccine efficacy, particularly vaccination of children, and a polarization of attitudes/beliefs among FSMs according to certain sociodemographic factors.

Anti-Vaccination Attitude and Vaccination Intentions Against Covid-19: A Retrospective Cross-Sectional Study Investigating the Role of Media Consumption

Objective

The present study explores, retrospectively, the link between anti-vaccination attitude and vaccination intentions and extends this relationship to the effect of media consumption style on attitude.

Method

Generalized linear mixed-models were used to estimate vaccination intentions (related to each of the four available vaccines at the time of the survey) relying on anti-vaccination attitude measured using the Italian translation of the Vaccination Attitude Examination (VAX) scale. Multiple linear regression was used to estimate which media type and which consumption frequency were responsible for variation in the anti-vaccination attitude.

Results

Greater anti-vaccination attitude led to lower vaccination intention (b=-8.33, p<.0001) confirming the attitude-intention link. Crucially, consuming vaccination related information via printed press weekly (b=-0.74, p=.0001) or daily (b=-0.96, p<.0001) were the only protective factors against developing anti-vaccination attitudes. On the other hand, discussing vaccination with the family physician weekly (b=0.66, p=.002) or even daily (b=0.52, p=.026), and actively looking for vaccination related information on specialized websites and blogs every day (b=0.64, t=2.78, p=.006) were risk factors related to increased anti-vaccination attitude. No effects of social media on anti-vaccination attitude were found.

Conclusions

The results confirm that vaccination intentions can be linked to the underlying anti-vaccination attitude. Moreover, our results suggest that the web and the blog sphere, but not social media, are the most anti-vaccination fuelling media and that health practitioners engage with the most vaccination-hesitant individuals. Further interventions could leverage these insights to tackle the vaccination hesitancy issue.

The Importance of Mapping Determinants, Attitudes and Beliefs of Vaccine Hesitancy in the Great Challenge of Compulsory Childhood Vaccination Comment on "Convergence on Coercion: Functional and Political Pressures as Drivers of Global Childhood Vaccine Mandates"

Vaccine hesitancy (VH) has risen significantly during the COVID-19 pandemic, becoming a major global health concern. VH is characterized by the delay or refusal of vaccination despite its availability. Various frameworks have been developed to understand the complex factors influencing VH, with attitudes, beliefs, and external influences being the most significant. The surge in VH has reignited the debate on the best approach to address it: persuasive/ educational or coercive. Attwell and Hannah studied the political and social reasons behind the adoption of mandatory vaccination in four jurisdictions (Italy, France, Australia, and California) due to declining vaccine coverage below the safety threshold. However, these methods may foster parental disbeliefs and opposition to vaccination campaigns. To combat VH, it is crucial to systematically assess its determinants within specific contexts and population groups. Increasing awareness about vaccination benefits, engaging with social media, and employing tailored strategies can foster spontaneous adherence to vaccination programs, eliminating the need for coercive measures.

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

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

Risk-efficacy framework - a new perspective on threat and efficacy appraisal and the role of disparity

The current study aims to provide a more nuanced understanding of threat and efficacy appraisal and account for the influence of disparity in the accessibility to risk prevention resources in predicting attitudes and behaviors. We propose a Risk-Efficacy Framework by integrating theories, including the extended parallel process model, health belief model, social cognitive theory, and construal level theory of psychological distance to achieve such a goal. An online survey targeting the U.S. population was conducted to empirically test the model (N = 729). The survey measured people's threat and efficacy appraisals related to COVID-19 and its vaccines and their attitudes and behavioral intention. The results of the survey supported the model's propositions. Specifically, perceived susceptibility moderated perceived severity's effects on attitudes and behaviors, such that perceived severity's influence attenuated as perceived susceptibility increased. Perceived accessibility to risk prevention resources moderated the influence of self and response efficacy. The former's effects on attitudes and behaviors increased, and the latter's effects decreased when perceived accessibility was high. The proposed framework provides a new perspective to examine the psychological determinants of prevention adoption and contributes to designing and implementing campaigns distributing prevention to underserved populations. The framework offers insights for risk managers such as public health authorities by articulating the dynamic nature of risks. When communicating early-stage lesser-known risks to the public, campaigns should highlight their severity and the response efficacy of risk solutions. Differently, more resources should be devoted to cultivating self-efficacy for widespread risks with more mitigation resources.

Exploring the Moderating Effect of Positive and Negative Word-of-Mouth on the Relationship between Health Belief Model and the Willingness to Receive COVID-19 Vaccine

This study indicates that the positive and negative effects of word-of-mouth (WOM) have an impact and moderating effect on vaccine uptake willingness, which is important to exploring the factors that affect vaccine uptake. We further analyzed the differences in the impact relationship between variables through questionnaire research. Based on the Health Belief Model (HBM) widely used to explore global health issues, this study focuses on Taiwanese residents and uses a questionnaire survey method. Furthermore, this study investigates the impact of various factors in the HBM on the willingness to receive the COVID-19 vaccine when faced with positive and negative word-of-mouth evaluations from the perspective of vaccine recipients, as well as whether WOM evaluations have an interference effect, along with the differences between variables. Practical recommendations are provided based on the research results, which can serve as a reference for future vaccine promotion programs and health promotion. By improving the national vaccination rate and achieving herd immunity, we aim to increase the persuasiveness of word-of-mouth on public healthcare decision-making. We also hope to provide a basis for health promotion and encourage people to make informed decisions about vaccination.

Identifying gaps in vaccination perception after mandating the COVID-19 vaccine in Saudi Arabia

OBJECTIVE

The burden of COVID-19 pandemic affected the globe, and it is unclear how it has impacted the general perception of other vaccines. We aimed to investigate the public awareness, knowledge, and attitude towards other complementary vaccines after the mandate of the COVID-19 vaccine.

METHODS

A cross-sectional study was conducted in Saudi Arabia using a survey distributed via several social media platforms in June 2022. The questionnaire had three main sections; awareness; attitudes; and demographic information. Descriptive analysis was mainly used and supplemented with Chi-square test for correlation. All individuals over the age of 18 were eligible to participate in the study.

RESULTS

A total of 1,045 participants from Saudi Arabia completed the survey. Of the respondents, 55.9% were female, and 95% were Saudi citizens. Public awareness towards vaccines after the mandate of COVID-19 vaccine was the highest with the influenza vaccine (98.2%), followed by human papillomavirus (HPV) (40.7%), tetanus, diphtheria, and pertussis (Tdap) (37.2%), and lastly, pneumococcal vaccine (17%). More than 50% of the participants expressed their willingness to receive any of the four vaccines if they knew about the benefits related to these vaccines.

CONCLUSION

The study showed that participants were willing to receive the vaccination if they were aware of the general benefits of vaccinations. Therefore, health education and campaigns toward recommended vaccines for high-risk group are essential and needed.

Acceptability of mandatory vaccination against influenza, measles, pertussis and varicella by workers in healthcare facilities: a national cross-sectional study, France, 2019

BACKGROUND

Vaccination of healthcare workers (HCW) aims to protect them and to reduce transmission to susceptible patients. Influenza, measles, pertussis, and varicella vaccinations are recommended but not mandatory for HCW in France. Insufficient vaccine coverage for these diseases in HCW has raised the question of introducing mandatory vaccination. We conducted a survey to estimate acceptability of mandatory vaccination for these four vaccines by HCW working in healthcare facilities (HCF) in France, and to identify associated determinants.

METHODS

In 2019, we performed a cross-sectional survey of physicians, nurses, midwives and nursing assistants working in HCF in France using a randomised stratified three-stage sampling design (HCF type, ward category, HCW category). Data were collected in face-to-face interviews using a tablet computer. We investigated the possible determinants of acceptability of mandatory vaccination using univariate and multivariate Poisson regressions, and estimated prevalence ratios (PR).

RESULTS

A total of 8594 HCW in 167 HCF were included. For measles, pertussis, and varicella, self-reported acceptability of mandatory vaccination (very or quite favourable) was 73.1% [CI95%: 70.9-75.1], 72.1% [69.8-74.3], and 57.5% [54.5-57.7], respectively. Acceptability varied according to i) HCW and ward category for these three vaccinations, ii) age group for measles and pertussis, and iii) sex for varicella. For mandatory influenza vaccination, acceptability was lower (42.7% [40.6-44.9]), and varied greatly between HCW categories (from 77.2% for physicians to 32.0% for nursing assistants).

CONCLUSION

HCW acceptability of mandatory vaccination was high for measles, pertussis and varicella but not as high for influenza. Vaccination for COVID-19 is mandatory for HCW in France. Replication of this study after the end of the COVID-19 crisis would help assess whether the pandemic had an impact on their acceptability of mandatory vaccination, in particular for influenza.

Impact of COVID-19 Pandemic on Human Papillomavirus Vaccine Uptake in Israel

OBJECTIVE

Isolation and school closure during the COVID-19 pandemic could decrease human papillomavirus (HPV) vaccination uptake and potentially increase future HPV-related morbidity among unvaccinated populations. The aim of our study was to investigate HPV vaccination rates in Israel during the pandemic.

METHODS

The HPV vaccination rates were compared before and during the COVID-19 pandemic years (2020-2021). Data regarding HPV vaccination between 2015 and 2021 were extracted from the Israeli Ministry of Health online reports. Vaccination rates were compared with other childhood vaccines, given at similar ages. Israeli HPV vaccination rates were further compared with England and Australia, which have an established vaccination infrastructure.

RESULTS

The average Israeli coverage of first-dose HPV vaccine was 60.2%, with significant variations from 2015 to 2021. During the pandemic years, first-dose vaccine coverage increased compared with the 3 previous years. The pandemic had also no apparent influence on other childhood vaccine uptake, even though adolescents in Israel missed many school days during this time. Average vaccine uptake in England and Australia was significantly higher than Israel ( p = .009); however, first-dose vaccination rates decreased considerably in England during 2020, to a nadir of 59%. The pandemic had little effect on HPV vaccination rates in Australia.

CONCLUSIONS

Despite many school days missed, the COVID-19 pandemic did not result in a decrease in HPV vaccine uptake in Israel. The pandemic could prove a good opportunity to further educate the public regarding the importance of whole-population vaccination programs. Implementing catch-up vaccination programs may bridge "vaccination gaps" that may be caused by future pandemics.

Human Papillomavirus Vaccine Hesitancy in the United States

Although the US Advisory Committee on Immunization Practices recommends vaccinating adolescents against the human papillomavirus (HPV) to prevent HPV-associated cancers, vaccine initiation and completion rates are suboptimal. Parental and provider hesitancy contributes significantly to low HPV vaccine uptake. This review describes sources of HPV vaccine hesitancy using a World Health Organization framework that categorizes determinants of vaccine hesitancy as follows: contextual factors (historical, sociocultural, environmental, or political factors), individual and group factors (personal perception or influences of the social/peer environment), and vaccine/vaccination-specific issues (directly related to vaccine or vaccination).

Identifying intervention strategies to improve HPV vaccine decision-making using behaviour change theory

Although the HPV vaccine is highly safe and effective, its uptake is sub-optimal in many countries, including Ireland. There is therefore a need to identify appropriate interventions that will increase HPV vaccine acceptance by parents. In this study, we took a systematic approach to understand the factors that influence HPV vaccine uptake by parents of adolescent girls in Ireland to define suitable behaviour change interventions that would support positive vaccine decision-making in the future. Specifically, we conducted semi-structured interviews, used a Theoretical Domains Framework (TDF)-based topic guide, to gain insight into the knowledge, beliefs, attitudes and current behaviours of parents with respect to their HPV vaccine decision. Transcripts were analysed using the TDF. The Behaviour Change Wheel (BCW) was used to identify relevant intervention functions and the Behaviour Change Technique Taxonomy version 1 (BCTTv1), to identify relevant intervention techniques. All parents discussed the essential role of healthcare providers in vaccine decision-making. Complacency and confidence were important factors in decision-making by vaccine hesitant parents. Five BCW intervention functions were identified as appropriate, namely; education; persuasion; environmental restructuring; modelling and enablement. To our knowledge, this is the first study to systematically evaluate HPV vaccine decision-making using behaviour change theory and identify suitable intervention strategies to promote positive vaccine decision-making using this approach.

Indiana Parental Perceptions of the Acceptability of General and HPV-Specific State Vaccine Requirements

State vaccine requirements are a tool for improving child and adolescent vaccination immunization coverage, but to be effective, parental buy-in is needed. The objective of this study was to assess the demographic, healthcare characteristics, and health beliefs associated with parental acceptance of general and HPV-specific state vaccine requirements. Indiana parents (N = 601) with children ages 11-17 years old completed a survey during March 2020.Results showed that 47.2% and 43.1% of parents believed there should always be general and HPV-specific state vaccine requirements, respectively. In multivariable analysis, higher odds of parental support for general state vaccine requirements were associated with being unsure whether HPV-associated cancer is a problem in the participant's county and having higher perceived benefits of HPV vaccines. Lower odds were associated with private insurance, having less than a bachelor's degree, and having less confidence in vaccines. In comparison, parents had higher odds of agreeing with HPV-specific state vaccine requirements if they reported higher interpersonal altruism and higher perceived benefits of HPV vaccines; they had lower odds if they were non-Hispanic White. Findings indicate that while similar percentages of parents agreed with general and HPV-specific state vaccine requirements, there were different characteristics associated with acceptance of each. Results can inform the development of tailored interventions for improving parental support for general and HPV-specific state vaccine requirements.

Attitudes towards mandatory vaccination and sanctions for vaccination refusal

AIMS

Investigating attitudes towards mandatory vaccination and sanctions for vaccination refusal in an area with insufficient vaccination coverage may help health authorities to assess which strategies for increasing vaccination coverage are appropriate. This study examines attitudes to vaccine mandates and asks questions regarding what kinds of sanctions could legitimately result from vaccination refusal. It seeks to find out if people's attitudes towards mandates and towards sanctions for vaccination refusal are related to their attitudes to vaccines and the degree of trust they feel towards health care professionals and health care authorities. The study also discusses how the observed attitudes towards mandates may be related to perceptions of autonomy, responsibility, and equitability.

METHODS

Data collection was carried out in Finland through an online survey in a region with suboptimal vaccine uptake. Statistical analysis was conducted on a sample of 1101 respondents, using confirmatory factor analysis and structural regression analysis.

RESULTS

Persons hold different views on mandates and sanctions. Importantly, the persons who support vaccination mandates and sanctions for vaccination refusal are to a great degree the same people who have positive attitudes to vaccines and high trust in health care professionals and health authorities.

CONCLUSION

Trust is a key factor which has a bearing on people's attitudes towards mandates and sanctions for noncompliance. A focus on the reasons for lack of trust, and on how to enhance trust, is a more feasible long-term way (than mandates) to promote large- scale compliance with childhood vaccine programmes in the studied country context.

People's perspectives about COVID-19 vaccination certificate: Findings from a representative Italian sample

In Italy, like in other countries, issues still exist regarding how to reach high vaccine coverage and several countries have considered policies to increase vaccine uptake. In the present study, we focused on people who have a favorable attitude towards vaccination. In March-April 2021, we asked a representative sample of Italian participants (N = 1,530) to assess to what extent they would support the adoption of a COVID-19 vaccination certificate, excluding unvaccinated people from participating in public and cultural events. Furthermore, as the vaccination coverage increases, severe forms of COVID-19 requiring hospitalization more likely involve unvaccinated individuals, who might be perceived as those who don't contribute to ending the pandemic and who constitute a significant health cost for society. We then asked participants to assess to what extent they would favor the idea of requiring people who refuse the vaccine to pay for their own medical expenses in case of hospitalization. We hypothesized that support for the adoption of the vaccination certificate would be predicted by the COVID-19 vaccination status (received, booked, high-, medium-, low-willingness to be vaccinated, or refused) and by the same factors that are known to affect the willingness to get vaccinated. These factors were also tested in a model aimed at investigating if a vaccinated person would favor a measure requiring the unvaccinated individuals to pay for medical expenses. Results confirmed that the support towards the vaccination certificate policy was strongly predicted by the vaccination status and by factors known to affect the willingness to get vaccinated. Interestingly (and surprisingly), a similar pattern was observed for the support of the policy about medical expenses. In conclusion, support for a COVID-19 vaccination certificate was high among the Italian population in the early phases of the vaccination rollout. The findings are discussed considering potential policies to tackle the pandemic.

Determinants of COVID-19 vaccine uptake among healthcare professionals and the general population in Cyprus: A web-based cross-sectional survey

OBJECTIVE

This study aims to examine the factors influencing COVID-19 vaccine uptake among healthcare professionals (HCPs) and the general population in Cyprus.

METHODS

A web-based cross-sectional study was conducted (November 2021-January 2022), using a self-administered, anonymous questionnaire to collect information covering a wide range of potential determinants including sociodemographic and health-related characteristics, trust in the healthcare system, satisfaction with it, utilization of preventive healthcare services, COVID-19 vaccination information and general vaccination knowledge.

RESULTS

A total of 2582 participants completed the survey. Overall, 53.5% of participants representing the general population, and 70.0% of the HCPs received the COVID-19 vaccination. We found that as the age increases by 1 year among the general population, the odds of being vaccinated against COVID-19 increase by 1.02 units (95% 1.00, 1.03, p= 0.035). In addition, participants among the general population with increased trust in national healthcare authorities' guidelines (OR = 3.96, 95% CI: 3.41, 4.61), and increased vaccination knowledge scores (OR = 1.11, 95% CI: 1.05, 1.18) were significantly more likely to be vaccinated, while those who had underage children living in the household were significantly less likely to be vaccinated against COVID-19 (OR = 0.68, 95% CI: 0.50, 0.91). Furthermore, male HCPs (OR = 1.91, 95% CI: 1.01, 3.59), and those who reported increased trust in national healthcare authorities' guidelines (OR = 5.38, 95% CI: 3.65, 7.95) were significantly more likely to be vaccinated.

CONCLUSION

Public health policymakers can use national campaigns and long-term planning to build public trust in national healthcare authorities and raise awareness about the benefits of vaccination. Such strategies could pave the way for adequate vaccine uptake and prepare the public for unfavourable scenarios, such as future pandemics.

Vaccine hesitancy and receipt of mandatory and optional pediatric vaccines in Shanghai, China

Given increased global concern about vaccine hesitancy, this study estimates coverage of mandatory vs non-mandatory vaccines in children, and assesses whether vaccine hesitancy among young parents relates to their child's eventual vaccination status in Shanghai, China. In a cohort study within Shanghai, China, we ascertained vaccine hesitancy among parents of young infants, and later abstracted their child's electronic immunization records. We measure full coverage of vaccines on the mandatory, and publicly funded Expanded Program on Immunization (EPI). Non-EPI vaccines included pneumococcal conjugate vaccine, Haemophilus influenzae type b vaccine, and rotavirus vaccine. Vaccine hesitancy was linked to vaccine uptake through mixed effects logistic regression models. Among 972 children, full coverage of all EPI vaccines by 15 months was 95%, compared to dose 1 coverage of pneumococcal conjugate vaccine at 13%, Haemophilus influenzae type b vaccine at 68%, and rotavirus vaccine at 52%. Vaccine hesitancy was not significantly linked with full coverage of all EPI vaccines (OR: 1.55, 95% CI: .89, 2.72), but coverage in the vaccine hesitant was lower for pneumococcal conjugate vaccine dose 1 (OR: .70, 95% CI: .53, .91), and rotavirus vaccine dose 1 (OR: .69, 95% CI: .56, .86). Disparities by education level were not significant for EPI vaccines, but were for dose 1 of pneumococcal conjugate vaccine rotavirus vaccine. Overall, vaccine hesitancy was related to lower uptake of non-EPI, but not EPI vaccines. Shanghai has a robust system for insurance equitable access to EPI vaccines, but if vaccine hesitancy grows, it could reduce coverage of non-EPI vaccines.

Assessment of training of general practice interns in motivational interviews about vaccination

The effectiveness of motivational interviewing (MI) for reducing vaccine hesitancy (VH) has been demonstrated in Quebec. We conducted a study to evaluate the acquisition of MI skills after MI training via videoconferencing for interns training as general practitioners (GPs) in southeastern France. A vaccination-specific MI training workshop was offered to interns in 2021, consisting of two separate Zoom videoconference sessions. Participants completed the Motivational Interviewing Skills in Immunization questionnaire before and after the training to measure skills acquisition. We used pairwise exact Wilcoxon-Pratt signed rank tests for the analysis. Among 45 GP interns enrolled in the first MI session, 34 (75.6%) attended both sessions and completed the questionnaire at 3 different time points. After the first session, MI knowledge scores improved significantly (+21.1 ± 21.6; P < .0001), as did application of MI skills (+36.8 ± 36.7; P < .0001), and MI practice confidence (+21.2 ± 11.1; P < .0001). The second MI session maintained the skills developed after the first session without further improvement. Participant satisfaction was high. This is the first study in France assessing the impact of a vaccination-specific MI training for GP interns. It shows a substantial improvement in knowledge, application of MI skills, and self-confidence in the practice of MI. GP interns were highly satisfied with the training despite the videoconference format. These promising results will allow the integration of MI training in GP medical curricula in order to prepare future GPs for communication in the field of vaccination.

Employee Participation in Workplace Vaccination Campaigns: A Systematic Review and Meta-Analysis

To reduce vaccine-preventable diseases in workers, workplace vaccination campaigns can be implemented on-site. The aim of this systematic review was to evaluate adherence to workplace vaccination campaigns. Three databases, PubMed, ISI Web of Science, and Scopus, were screened systematically for articles in English or Italian addressing participation in an on-site vaccination program by employees. The following data was extracted: authors, year, country, type of vaccine, type of workplace, sample size, vaccination rate. Data on the prevalence of flu vaccination were calculated and pooled using a random-effects model. Thirteen articles were included in the review, ten in the meta-analysis. Most studies were conducted in the USA (30.7%) and most vaccination campaigns were against influenza (69.2%), with a pooled estimate of 42% (95% CI: 0.25-0.60%); participation rate was highly variable, ranging from 88.9% for an influenza vaccination campaign to 5.7% for a Lyme disease vaccination campaign. Offering free on-site vaccination can be a successful tool to ensure adherence to vaccination campaigns and administration of all required doses according to the vaccine administration scheme. The occupational physician can play a key role in implementing workplace campaigns for employee mandatory vaccinations.

Misrepresentation and Nonadherence Regarding COVID-19 Public Health Measures

Importance

The effectiveness of public health measures implemented to mitigate the spread and impact of SARS-CoV-2 relies heavily on honesty and adherence from the general public.

Objective

To examine the frequency of, reasons for, and factors associated with misrepresentation and nonadherence regarding COVID-19 public health measures.

Design, Setting, and Participants

This survey study recruited a national, nonprobability sample of US adults to participate in an online survey using Qualtrics online panels (participation rate, 1811 of 2260 [80.1%]) from December 8 to 23, 2021. The survey contained screening questions to allow for a targeted sample of one-third who had had COVID-19, one-third who had not had COVID-19 and were vaccinated, and one-third who had not had COVID-19 and were unvaccinated.

Main Outcomes and Measures

The survey assessed 9 different types of misrepresentation and nonadherence related to COVID-19 public health measures and the reasons underlying such behaviors. Additional questions measured COVID-19-related beliefs and behaviors and demographic characteristics.

Results

The final sample included 1733 participants. The mean (SD) participant age was 41 (15) years and the sample predominantly identified as female (1143 of 1732 [66.0%]) and non-Hispanic White (1151 of 1733 [66.4%]). Seven hundred twenty-one participants (41.6%) reported misrepresentation and/or nonadherence in at least 1 of the 9 items; telling someone they were with or about to be with in person that they were taking more COVID-19 preventive measures than they actually were (420 of 1726 [24.3%]) and breaking quarantine rules (190 of 845 [22.5%]) were the most common manifestations. The most commonly endorsed reasons included wanting life to feel normal and wanting to exercise personal freedom. All age groups younger than 60 years (eg, odds ratio for those aged 18-29 years, 4.87 [95% CI, 3.27-7.34]) and those who had greater distrust in science (odds ratio, 1.14 [95% CI, 1.05-1.23]) had significantly higher odds of misrepresentation and/or nonadherence for at least 1 of the 9 items.

Conclusions and Relevance

In this survey study of US adults, nearly half of participants reported misrepresentation and/or nonadherence regarding public health measures against COVID-19. Future work is needed to examine strategies for communicating the consequences of misrepresentation and nonadherence and to address contributing factors.

Vaccine Hesitancy: Contemporary Issues and Historical Background

Vaccination, despite being recognized as one of the most effective primary public health measures, is viewed as unsafe and unnecessary by an increasing number of individuals. Anxiety about vaccines and vaccination programs leading to vaccine hesitancy results from a complex mix of social and political influences, cultural and religious beliefs, the availability of and ability to interpret health and scientific information, and personal and population experiences of health systems and government policies. Vaccine hesitancy is becoming a serious threat to vaccination programs, and was identified as one of the World Health Organization’s top ten global health threats in 2019. The negative impact of anti-vaccination movements is frequently cited as one of the major reasons for rising vaccine hesitancy amongst the general public world-wide. This review discusses the various issues surrounding vaccine hesitancy and the anti-vaccine movement, starting with the definitions of vaccine hesitancy and the anti-vaccine movement in their early history and in the modern era, before discussing the key drivers of vaccine hesitancy, particularly across different regions of the world, with a focus on various countries with low-, middle-, or high-income economies with different socio-economic populations. The review concludes with the impact of vaccine hesitancy on herd immunity and social, psychological, and public health measures to counter vaccine hesitancy.

An Overview of Strategies to Improve Vaccination Compliance before and during the COVID-19 Pandemic

The debate on vaccination mandate was fuelled over the past two years by the COVID-19 pandemic. This study aimed at overviewing vaccination strategies and corresponding vaccine coverages for childhood vaccinations before the pandemic and for SARS-CoV-2 in high-income countries. A qualitative comparison was also performed between the two contexts: unlike for childhood vaccinations, only one European country (Austria) imposed generalised COVID-19 mandates, most countries preferring targeted mandates for higher-risk categories (Italy, Greece) or workers in key public services (Finland, Australia, New Zealand, UK, Germany). Many countries (Norway, Sweden, Netherlands, Portugal, Spain) confirmed their traditional voluntary vaccination approach also for COVID-19, while others (Slovenia and Hungary), historically relying on compulsory vaccination strategies, surprisingly opted for voluntary SARS-CoV-2 vaccination, with unsatisfactory results in terms of immunisation rates. However, no tangible relationship was generally found between vaccination policies and immunisation coverages: data show that, unlike some countries with mandates, countries where vaccinations are merely recommended could achieve higher coverages, even beyond the recommended 95% threshold. The COVID-19 experience has enriched pre-existent vaccination strategy debates by adding interesting elements concerning attitudes towards vaccines in a novel and unexplored context. Interpreting the available results by considering the different cultural contexts and vaccine hesitancy determinants can help to better understand the complexity of the relationship between policies and achieved coverages.

Medical student attitudes on vaccination relevance: A mixed-method study

Background and objectives

The study aims to investigate the attitudes of medical students regarding the importance and relevance of vaccinations, whether vaccinations should be compulsory and how to employ a new teaching concept to deal with vaccination-critical parents.

Methods

This mixed-method study consists of a quantitative questionnaire and focus groups. Quantitative data were analysed by calculating the descriptive statistics, and interviews were analysed using Mayring’s content analysis.

Results

A total of 170 medical students completed the questionnaire, and 59 students participated in 9 focus groups. Students reported that they felt more confident dealing with vaccination-critical parents after learning the new teaching concept. Similar results were found for medical students prior to and during the pandemic. During the pandemic, medical students viewed vaccinations for several diseases, such as measles or COVID-19, as important (range: M = 3.56, SD = 0.54 to M = 3.97, SD = 0.17). Similar results were found for medical students prior to the pandemic (range: M = 3.26, SD = 0.77 to M = 3.94, SD = 0.24). In the focus groups, however, medical students displayed controversial attitudes regarding compulsory vaccinations.

Conclusions

While the medical students agreed on the use of vaccination for highly infectious diseases, their level of agreement decreased depending on the severity of the disease. Practical recommendations that come out of the study are creating a trustful relationship with and delivering information to patients.

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

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

Analysis on vaccine hesitation and its associated factors among parents of preschool children in Songgang Street, Shenzhen

China has the largest number of vaccinated population around the world. However, there has been few research on the prevalence and associated factors of vaccine hesitation among parents of preschool children. Therefore, we conducted this study to evaluate the status of vaccine hesitation and its associated factors among children’s parents. A cluster random sampling method was adopted to select six community health service centers in Shenzhen, and parents of preschool children who were immunized in the vaccination outpatient department of the selected community health centers were surveyed using a structured self-administered questionnaire. Vaccine hesitation was assessed by the Parent Attitudes about Childhood Vaccines (PACV) scale. A multiple linear regression analysis was used to assess the associated factors for vaccine hesitance among children's parents. A total of 1025 parents (response rate, 93.18%) filled out the questionnaires. The average score of vaccine hesitancy was 43.37 (SD = 10.34) points. 23.61% of parents wanted children to get all the recommended shots, 53.76% of them did not believe that many of the illnesses shots prevent were severe, and 75.41% of them could not guarantee the information they receive about shots. The results of multiple linear regression showed that the number of children in the family (β = −0.93, 95% CI: −1.31 to 0.54), health status of the child (β = 0.47, 95% CI: 0.07 to 0.87), education level of the parents (Father: β = −0.84, 95%CI: −1.37 to 0.31; Mother: = −1.59, 95%CI:−2.13 to −1.05), and annual family income (β = 1.64, 95%CI: 1.13–2.16) were significantly associated with vaccine hesitation. The average score of parents' vaccine hesitation in Shenzhen was 43.37. The results showed that the number of children in the family, health status of the children, education level of the parents and annual family income were important factors associated with the parents' vaccine hesitation.

'Leading from the front' implementation increases the success of influenza vaccination drives among healthcare workers: a reanalysis of systematic review evidence using Intervention Component Analysis (ICA) and Qualitative Comparative Analysis (QCA)

BACKGROUND

Seasonal influenza vaccination of healthcare workers (HCW) is widely recommended to protect staff and patients. A previous systematic review examined interventions to encourage uptake finding that hard mandates, such as loss of employment for non-vaccination, were more effective than soft mandates, such as signing a declination form, or other interventions such as incentives. Despite these overarching patterns the authors of the review concluded that 'substantial heterogeneity' remained requiring further analysis. This paper reanalyses the evidence using Intervention Component Analysis (ICA) and Qualitative Comparative Analysis (QCA) to examine whether the strategies used to implement interventions explain the residual heterogeneity.

METHODS

We used ICA to extract implementation features and trialists' reflections on what underpinned the success of the intervention they evaluated. The ICA findings then informed and structured two QCA analyses to systematically examine associations between implementation features and intervention outcomes. Analysis 1 examined hard mandate studies. Analysis 2 examined soft mandates and other interventions.

RESULTS

In Analysis 1 ICA revealed the significance of 'leading from the front' rather than 'top-down' implementation of hard mandates. Four key features underpinned this: providing education prior to implementation; two-way engagement so HCW can voice concerns prior to implementation; previous use of other strategies so that institutions 'don't-go-in-cold' with hard-mandates; and support from institutional leadership. QCA revealed that either of two configurations were associated with greater success of hard mandates. The first involves two-way engagement, leadership support and a 'don't-go-in-cold' approach. The second involves leadership support, education and a 'don't-go-in-cold' approach. Reapplying the 'leading from the front' theory in Analysis 2 revealed similar patterns.

CONCLUSIONS

Regardless of intervention type a 'leading from the front' approach to implementation will likely enhance intervention success. While the results pertain to flu vaccination among HCWs, the components identified here may be relevant to public health campaigns regarding COVID-19 vaccination.

Mandatory COVID-19 Vaccination for Healthcare Professionals and Its Association With General Vaccination Knowledge: A Nationwide Cross-Sectional Survey in Cyprus

COVID-19 compulsory vaccination for healthcare professionals (HCPs) is a sensitive and controversial topic, with different support rates worldwide. Previous studies in Cyprus identified a low COVID-19 vaccination acceptance among HCPs, however, no studies have investigated their perceptions toward mandatory COVID-19 vaccination. This is the first study to investigate the attitudes of HCPs toward mandatory COVID-19 vaccination and its association with general vaccination knowledge. A cross-sectional study was conducted, using an online self-administered, anonymous questionnaire to collect data on sociodemographic and health-related characteristics, trust and satisfaction with the healthcare system, utilization of preventive healthcare services, COVID-19 vaccination information, vaccination knowledge, and attitudes among HCPs toward mandatory COVID-19 vaccination. A total of 504 HCPs participated in the survey, with 34% being in favor of mandatory COVID-19 vaccination. A sufficient vaccination knowledge score was identified among the HCPs, with higher scores being associated with mandatory vaccination support (p < 0.001). As age increases by one year, the odds of supporting mandatory vaccination increase by 1.03 units (95% CI: 1.01-1.06). In addition, as the general vaccination knowledge score increases by one unit, the odds of supporting mandatory COVID-19 vaccination increase by 1.55 units (95% CI: 1.33-1.81). Our findings show that about two-thirds of the HCPs in Cyprus were opposed to a mandatory COVID-19 vaccination policy. Older age and general vaccination knowledge were found to be the strongest predictors of mandatory vaccination support. To avoid unforeseen outcomes, mandatory vaccination policies should be implemented with caution and consultation.

The Long-Term Success of Mandatory Vaccination Laws After Implementing the First Vaccination Campaign in 19th Century Rural Finland

In high-income countries, childhood infections are on the rise, a phenomenon attributed in part to persistent hesitancy toward vaccines. To combat vaccine hesitancy, several countries recently made vaccinating children mandatory, but the effect of such vaccination laws on vaccination coverage remains debated, and the long-term consequences are unknown. Here we quantified the consequences of vaccination laws on vaccination coverage, monitoring for a period of 63 years (1837-1899) rural Finland's first vaccination campaign against the highly lethal childhood infection smallpox. We found that annual vaccination campaigns were focused on children up to 1 year old and that their vaccination coverage was low and declined over time until the implementation of the vaccination law, which stopped the declining trend and was associated with an abrupt coverage increase, of 20%, to cover >80% of all children. Our results indicate that vaccination laws can have a long-term beneficial effect of increasing the vaccination coverage and will help public health practitioners to make informed decisions on how to act against vaccine hesitancy and optimize the impact of vaccination programs.

Attitudes and Determinants of Mandatory Vaccination against COVID-19 among the General Population of Cyprus: A Nationwide Cross-Sectional Study

Vaccinations for the prevention of coronavirus disease (COVID-19) are important to control the ongoing pandemic. A much-discussed strategy to increase vaccination coverage is mandatory vaccination; however, its legitimacy and effectiveness as a measure are doubtful. This study aims to investigate the attitudes of the general population of Cyprus towards COVID-19 mandatory vaccination and to identify the factors influencing individuals’ attitudes towards such policy. An online cross-sectional study was conducted, using a self-administered, anonymous questionnaire to collect information on sociodemographic and health-related characteristics, trust, and satisfaction about the healthcare system and utilization of preventive healthcare services, COVID-19 vaccination information, general vaccination knowledge, and attitudes towards mandatory vaccination. A total of 2140 participants completed the survey, with 27.8% being in favor of mandatory vaccination. We found that as the age increases by one year, the odds of supporting mandatory vaccination increase by 1.04 units (OR 1.04, 95% CI: 1.02–1.05). In addition, those who reported increased trust in national healthcare authorities’ guidelines and recommendations (OR 3.74, 95% CI: 3.11–4.49) and those satisfied with the healthcare system (OR 1.38, 95% CI: 1.16–1.65) and follow doctor’s instructions (OR 1.29, 95% CI: 1.03–1.61), were significantly more likely to support mandatory vaccination while those who had underage children living in the household were significantly less likely to support mandatory vaccination (OR 0.69, 95% CI: 0.50–0.94). Public health authorities need to develop well-organized vaccination campaigns in which accurate evidence-based information would be disseminated with respect to individuals’ autonomy.

Awareness of COVID-19 Symptoms, Risk Factors, and Vaccinations in Patients with Multiple Sclerosis

Multiple Sclerosis (MS) is the most common chronic autoimmune disease of the central nervous system, affecting around 2.8 million people worldwide. Patients’ knowledge about COVID-19 infection, and their proper protective actions, may reduce the risk of infection. The aim of this study was to assess the knowledge of patients with MS about SARS-CoV-2, COVID-19 illness, the relationship between MS and COVID-19, willingness to be vaccinated, and the impact of the pandemic on MS care. An original, anonymous, 35-items, self-reported questionnaire was used in both web-based and on-site survey formats. Two-hundred and forty-eight questionnaires were analyzed (mean age 40.8 ± 10.6 years, 77.8% women). Participants reported the use of multiple sources of information, and the most common were websites (77.8%) and television (59.3%). The majority of participants knew the correct symptoms of COVID-19 or transmission routes (94.4%), and accepted the pandemic’s restrictions (96.8%). A total of 93.2% considered SARS-CoV-2 as highly infectious, and 69% thought they were at higher risk of being infected with SARS-CoV-2, mainly because of immunodeficiency (82.7%). Although most of them were afraid of COVID-19 (69.0%), only two-thirds wanted to be vaccinated. Patients who were afraid of COVID-19 had a 3.5-times higher chance to declare willingness for vaccination. A total of 29.8% patients claimed that the COVID-19 pandemic limited access to the healthcare system. This study shows that Polish patients with MS represent a good level of knowledge about COVID-19 disease, and acceptance for public rules, but their willingness for vaccinations is not sufficient. Country-wide educational campaigns should be conducted, particularly on the internet and TV. Restrictions in healthcare facilities should be balanced to secure access for patients with MS.

How colleges intervene to increase student body vaccination coverage

OBJECTIVE

The interventions colleges use to help students be compliant with vaccinations is unknown. This study describes colleges' use of practices consistent with Centers for Disease Control and Prevention (CDC) recommendations to encourage student body vaccination.

PARTICIPANTS

Participants were a convenience sample of 136 student health center (SHC) administrators from colleges across the U.S.

METHODS

An online survey assessed SHCs' use of various practices, policies and services to improve student body vaccination coverage.

RESULTS

There was wide variability in use of evidence-based interventions overall and with respect to specific vaccinations. While most SHCs (92.7%) coordinated vaccination outreach events on campus, only half (50%) accessed an immunization registry to verify vaccination histories. While 88.6% requested student vaccination histories for MMR, only 39.7% requested it for human papillomavirus (HPV).

CONCLUSIONS

The discrepancies in SHC implementation of interventions to increase coverage of the recommended vaccinations for students suggest that helping colleges expand their capacity to intervene may decrease coverage rate disparities.

Tetanus Vaccination Status and Vaccine Hesitancy in Amateur Basketball Players (Italy, 2020)

Basketball is among the third most popular team sport in Italy. Albeit not usually perceived as being at high risk for tetanus, the Italian legal framework (Law No. 292 of 1963; Presidential Decree 1301/1965) requires tetanus vaccination (TeV) even for amateur practice. Even though some previous reports have suggested a relatively low adherence towards vaccination practice among basketball player, corresponding knowledge, attitudes and practices towards TeV remain largely unknown. Our study specifically investigated such topics in a total of 270 amateur basketball players participating into an internet-based survey by completing a structured questionnaire. Of them, 73.0% had a proper vaccination status, but a third of respondents (33.3%) exhibited some degree of vaccine hesitancy. The average understanding of TeV and tetanus (79.8% with a potential range 0–100) as well as the risk perception for natural infection (63.9% ± 26.6) were quite good. Even though unmotivated fears towards TeV were more scarcely reported (14.0% ± 15.4), they still represented the main reasons for having missed vaccination shots (63.0%). Knowledge status and risk perception for natural infection and TeV were well correlated (R = 0.22 and R = −0.64, respectively). Appropriate TeV status was more likely in respondents not exhibiting vaccine hesitancy (Odds Ratio (OR) 0.114, 95% Confidence Interval (95%CI) 0.059–0.225). In turn, vaccine hesitancy was more frequently reported among individuals of male gender (OR 3.148, 95%CI 1.072–9.244), while better formal education (OR 0.065, 95%CI 0.013–0.319) and working in healthcare settings (OR 0.042, 95%CI 0.007–0.265) were characterized as negative effectors. Vaccinations in athletes represent an often overlooked issue, with a considerable lack of available evidence. The results stress the opportunity for appropriate TeV screening programs among amateur athletes and the potential relevance of interventions aimed at raising the perceived significance of TeV in order to cope with a significant share of vaccine-hesitant athletes.

Knowledge, Attitudes and Practices towards SARS-CoV-2 vaccination among morbid obese individuals: a pilot study

BACKGROUND AND AIM

Vaccinations have dramatically impacted on the ongoing pandemic of COVID-19, the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As morbid obese (MO) individuals are at high risk for severe complications, their acceptance of SARS-CoV-2 vaccines is of certain public health interest.

METHODS

We investigated the knowledge, attitudes and eventual acceptance of SARS-CoV-2/COVID-19 vaccination among MO individuals either in waiting list, or recipients of bariatric surgery from a reference center (Parma University Hospital) shortly before the inception of the Italian mass vaccination campaign (March 2021). Data were collected through a web-based questionnaire. Association of individual factors with acceptance of SARS-CoV-2 vaccine was assessed by means of a logistic regression analysis with eventual calculation of adjusted Odds Ratios (aOR) and corresponding 95% Confidence Intervals (95%CI).

RESULTS

Adequate, general knowledge of SARS-CoV-2/COVID-19 was found in the majority of MO patients. High perception of SARS-CoV-2 risk was found in around 80% of participants (79.2% regarding its occurrence, 73.6% regarding its potential severity). Acceptance of SARS-CoV-2/COVID-19 vaccination was reported by 65.3% of participants, and was more likely endorsed by MO patients who were likely to accept some sort of payment/copayment (aOR 5.783; 1.426; 23.456), or who were more likely towards a vaccination mandate (aOR 7.920; 1.995; 31.444).

CONCLUSIONS

Around one third of the MO individuals among potential recipient of bariatric surgery exhibited some significant hesitancy towards SARS-CoV-2 vaccine, and a rational approach may fail to capture and address specific barriers/motivators in this subset of individuals, stressing the importance for alternative interventions. (www.actabiomedica.it).

Preclinical Pharmacokinetics, Biodistribution, and Acute Toxicity Evaluation of Caerin 1.9 Peptide in Sprague Dawley Rats

Caerin 1.9 is a natural peptide derived from the skin secretions of the Australian tree frog (Litoria) with broad-spectrum antimicrobial and anticancer bioactivity. It improves the efficacy of a therapeutic vaccine and immune checkpoint inhibitor therapy when injected intratumorally and inhibits TC-1 tumor growth when applied topically through intact skin in a TC-1 murine tumor model. This paper investigated the pharmaceutical kinetic profile, the tissue distribution, and the acute safety investigation of Caerin 1.9 peptide in Sprague Dawley (SD) rats. The results showed that subcutaneous injection of Caerin 1.9 at 100 mg/kg is safe and does not cause mortality or organ malfunction in the recipient rats. For the consecutive injection of F3 at 10 mg/kg, the peak concentration (C _max) of F3 displayed at 1 hr after injection in male rats was 591 ng/mL, the average drug retention time was 0.807 hr, T _1/2 was 4.58 hr, and AUC_0-last was 1890 h × ng/mL. In female rats, C _max was 256 ng/mL, with an average drug retention time of 2.96 hr, T _1/2 of 1.33 hr, and AUC_0-last of 740 h × ng/mL. The results showed that the concentration of Caerin 1.9 in the peripheral blood peaked at 1 hour. As injected concentration increased, T _1/2 extended, and C _max, AUC_0-last, and volume of distribution at a steady state all increased. After 14 days of repeated subcutaneous injection at 10.0 mg/kg, no accumulation of Caerin 1.9 in plasma was observed. The results of tissue distribution showed that the Caerin 1.9 is below the LC-MS/MS detection threshold at a minimum concentration of 40 ng/g. In conclusion, Caerin 1.9 is well tolerated in rats and could be used with current immunotherapies for better management of solid tumors and genital warts.

Who is more likely to hesitate to accept COVID-19 vaccine: a cross-sectional survey in China

BACKGROUND

The aim of our study was to identify factors associated with coronavirus disease 2019 (COVID-19)vaccine willingness in China to aid future public health actions to improve vaccination.

RESEARCH DESIGN AND METHODS

This study was conducted in August 2020 using a mixed-method approach, including a cross-sectional self-administered anonymous questionnaire survey and in-depth interviews with community residents in China.

RESULTS

: Of the participants, 30.9% showedCOVID-19 vaccine hesitancy. Being female(OR=1.297), having poor health(OR=1.312), having non-health or medical-related occupations (OR=1.129), no COVID-19 infection experience(OR=1.523), living with vulnerable family members(OR=1.294), less knowledge(OR=1.371), less attention to COVID-19 information(OR=1.430), less trust in official media(OR=1.336), less perceived susceptibility to COVID-19(OR=1.367), and less protective behavior(OR=1.195) were more likely to hesitate. Qualitative research has shown that they doubt the importance and necessity, as well as the effectiveness and safety of the vaccination. The economic and service accessibility of the vaccination was an impediment to their vaccine acceptance.

CONCLUSION

Nearly one-thirdof people showed hesitancy to accept COVID-19 vaccination in China. Our findings highlight that health communication and publicity should be performed for the targeted population, and immunization programs should be designed to remove underlying barriers to vaccine uptake.

COVID-19 Immunisation, Willingness to Be Vaccinated and Vaccination Strategies to Improve Vaccine Uptake in Australia

The COVID-19 vaccine rollout is crucial to lifting community and economic restrictions. This cross-sectional study aimed to assess: (a) COVID-19 vaccine uptake and associated factors; (b) COVID-19 vaccine intentions and associated factors; (c) community support for COVID-19 vaccination strategies and associated factors. The survey was conducted between May and July 2021 in Australia. Of 3003 participants, 30% reported they were already vaccinated and 39% indicated they would get vaccinated. Low socioeconomic and education levels, non-English speaking backgrounds and being parents were associated with decreased vaccine willingness and/or vaccination rates. High levels of support for vaccination strategies were demonstrated with mandatory vaccination being less preferable. Respondents from non-English speaking backgrounds were more likely to support a mandatory vaccination policy. Respondents with the highest socioeconomic level were more likely to support vaccination requirements for international travel, visiting nursing homes and working in healthcare settings. Respondents who were aged ≥70 years were more likely to support all proposed vaccination strategies. Targeted campaigns should be implemented for parents and those who live in socioeconomic disadvantaged areas and have lower educational attainment. Concise and clear vaccine information should be provided in lay and multiple languages to improve vaccine confidence. Vaccine enforcement policies should be considered and implemented with caution.

Development and validation of the knowledge and attitude regarding childhood vaccination (KACV) questionnaire among healthcare workers: the Malay version

Health care workers play an important role in supporting childhood vaccination as they are the most trusted source of vaccine-related information for parents. However, there is limited validated tools to measure their knowledge and attitude on childhood vaccination. This study aims to develop and validate knowledge and attitude regarding childhood vaccination (KACV) questionnaire among healthcare workers. The questionnaire was developed based on literature reviews and underwent a sequential validation process, including content, face validity and exploratory factor analysis. However, the attitude section is unidimensional and has undergone reliability analysis only. The preliminary knowledge questionnaire contains 33 items and the attitude questionnaire consists of 17 items. The preliminary KACV showed a high item Content Validity Index and Face Validity Index. The final questionnaire consists of 10 items for knowledge and 15 items for attitude. The Cronbach alpha for the knowledge and attitude section were 0.896 and 0.861, respectively. KACV is a valid and reliable tool to measure healthcare workers' knowledge and attitude on childhood vaccination.

Understanding parents' views toward the newly enacted HPV vaccine school entry policy in Puerto Rico: a qualitative study

BACKGROUND

The Human papillomavirus vaccine (HPV) is an essential tool for the prevention of HPV-related cancers. In Puerto Rico, the Secretary of Health established a school entry requirement of at least one dose of HPV vaccination in girls and boys aged 11 and 12 years, taking effect in August 2018. Our study aimed to examine parents' and guardians' views of unvaccinated children about the process of implementation of the new HPV vaccination school entry policy in Puerto Rico and identify potential barriers and facilitators related to the implementation of this requirement.

METHODS

During April through November 2019, we conducted three focus groups (n = 12) and eight in-depth semi-structured interviews with parents of children aged 11 and 12 who had not yet initiated the HPV vaccine series. The interview topics addressed were: perception of vaccination, HPV vaccine and it is inclusion as new school entry requirement practice, procedure of the sources of information, influencers, and willingness to change. The interviews were recorded and transcribed by our staff members. We identified emergent themes through thematic analysis.

RESULTS

The participants' perspective on the HPV vaccine school requirement was mixed. Lack of information of the HPV vaccines and lack of communication about the school-entry requirement were the themes most mentioned in the interviews. Moreover, previous negative experiences from friends or family members and adverse effects deterred some participants from vaccinating their kids. We discussed barriers in the process of soliciting an exemption.

CONCLUSION

Most barriers mentioned by study participants are modifiable. Information about the HPV vaccine mandate's implementation and educational materials regarding HPV vaccine safety need to be provided to address parents' concerns related to the vaccine's side effects. Schools (teachers, principal directors, and administrative staff), the government, and parent organizations need to be part of these efforts. This multilevel approach will help to improve disseminating information about HPV vaccination to clarify doubts and misinformation among parents.

Effectiveness of Mandatory and Incentive-Based Routine Childhood Immunization Programs in Europe: A Systematic Review of the Literature

There is a lack of comprehensive and systematic data and evidence regarding the effectiveness of mandatory and incentive-based vaccination schemes. The results of such programs in some countries have not been adequately studied. A number of countries have recently introduced tightening vaccination measures, and it is important to analyze and assess the results of these programs. The unprecedented situation due to the COVID-19 pandemic and mass vaccination made the topic of the effectiveness of vaccination policies and mandates even more relevant. The aim of the study is to assess childhood vaccination programs implemented in selected countries. The study focuses on initiatives implemented in the European Region of the World Health Organization (WHO). A total of 466 full-text articles were assessed for eligibility, and 26 articles on seven countries were included in the synthesis. Additionally, we obtained and performed an analysis of data on the impact of COVID-19 on vaccine coverage and incidence of vaccine-preventable diseases, and the implementation of vaccine mandates in the selected countries. The evidence collected and analyzed in this review allowed us to conclude that the introduction of children routine vaccination mandates increases vaccine coverage and reduces the incidence of vaccine-preventable diseases when compared to the situation before the introduction of the mandates.

COVID-19 Vaccine Hesitancy and Resistance in India Explored through a Population-Based Longitudinal Survey

BACKGROUND

The World Health Organization has recommended that individual governments identify vaccine hesitancy areas. It is proposed that the governments, with the aid of local organizations, educate and implement social insights on the vaccination so that high population levels are covered with this safe immune program.

METHODS

A longitudinal online survey covered 3000 adults from India. We examined the demography, behavioral (socio-economic) attitude, vaccine hesitancy, vaccine resistance for the COVID-19 vaccine. The specific reasons for the COVID-19 vaccine decline were also evaluated.

RESULTS

Our survey revealed 59% definite response, 29% low-level response, and 7% high-level response for vaccine hesitancy, while 6% had resistant views on the COVID-19 vaccine. Individuals who had higher income levels, lived in a society, maintained social distancing, had downloaded the COVID-19 update app, showed a positive attitude towards their government, and more confidence in their healthcare system were more inclined towards the vaccination. On the contrary, individuals who had overstated the risks of COVID-19 and had a religious and populistic attitude towards vaccination were more hesitant/resistant to vaccination. The respondents who declined vaccine administration were further evaluated for their specific reason for their response. The most common reasons for declining the COVID-19 vaccine were post-vaccine scare of adverse health effects and accepting the information spread by social media.

CONCLUSIONS

The results in our study show that by identifying population "hot spots" that have negative or unclear information on the COVID-19 vaccination, these "hot spots" can be addressed by involving friendly organizations that can clear their strong disbeliefs and increase the percentage of vaccine-definite people within the population. The role of government-induced COVID-19 vaccine policy measures can always be beneficial to cause this shift from disbelief to confidence within the population.

Arabic validation and cross-cultural adaptation of the 5C scale for assessment of COVID-19 vaccines psychological antecedents

BACKGROUND

In the Arab countries, there has not been yet a specific validated Arabic questionnaire that can assess the psychological antecedents of COVID-19 vaccine among the general population. This study, therefore, aimed to translate, culturally adapt, and validate the 5C scale into the Arabic language.

METHODS

The 5C scale was translated into Arabic by two independent bilingual co-authors, and then translated back into English. After reconciling translation disparities, the final Arabic questionnaire was disseminated into four randomly selected Arabic countries (Egypt, Libya, United Arab Emirates (UAE), and Saudi Arabia). Data from 350 Arabic speaking adults (aged ≥18 years) were included in the final analysis. Internal consistency was assessed by Cronbach's alpha. Construct validity was determined by concurrent, convergent, discriminant, exploratory and confirmatory factor analyses.

RESULTS

Age of participants ranged between 18 to 73 years; 57.14% were females, 37.43% from Egypt, 36.86%, from UAE, 30% were healthcare workers, and 42.8% had the intention to get COVID-19 vaccines. The 5 sub-scales of the questionnaire met the criterion of internal consistency (Cronbach's alpha ≥0.7). The predictors of intention to get COVID-19 vaccines (concurrent validity) were young age and the 5C sub-scales. Convergent validity was identified by the significant inter-item and item-mean score of the sub-scale correlation (P<0.001). Discriminant validity was reported as inter-factor correlation matrix (<0.7). Kaiser-Meyer-Olkin sampling adequacy measure was 0.80 and Bartlett's sphericity test was highly significant (P<0.001). Exploratory factor analysis indicated that the 15 items of the questionnaire could be summarized into five factors. Confirmatory factor analysis confirmed that the hypothesized five-factor model of the 15-item questionnaire was satisfied with adequate psychometric properties and fit with observed data (RMSEA = 0.060, GFI = 0.924, CFI = 0.957, TLI = 0.937, SRMR = 0.076 & NFI = 906).

CONCLUSION

The Arabic version of the 5C scale is a valid and reliable tool to assess the psychological antecedents of COVID-19 vaccine among Arab population.

Determinants of parental hesitancy to vaccinate their children against COVID-19 in China

Vaccine hesitancy seriously hinders herd immunity. We explored the determinants of parental hesitancy to vaccinate children against Coronavirus Disease 2019 (COVID-19) in China.A population-based self-administered online questionnaire evaluating parental hesitancy in vaccinating their children against COVID-19 was conducted in Taizhou, China. Of the 2463 parents who received the invitation, 1788 (72.6%) responded to the survey.Of the repondents, 52.5% were hesitant. Mothers exhibited a greater proportion of vaccine hesitancy than fathers did (57.5% vs. 41.7%, P < 0.001). Multiple logistic regression analysis indicated that parents with children under 18 years of age (OR = 0.94, 95%CI: 0.90-0.99), lower knowledge scores about COVID-19 vaccination (Q1: OR = 1.92, 95%CI: 1.37-2.69; Q2: OR = 1.51, 95%CI: 1.10-2.08), lower awareness of the permission of vaccinating children (OR = 1.74, 95%CI: 1.36-2.23) and hesitancy to inoculate themselves (OR = 8.18, 95%CI: 6.48-10.33) were associated with parental hesitancy to inoculate their children. Results also revealed the disparity between fathers and mothers regarding associated factors.This study found that a substantial proportion of parents reported being hesitant to vaccinate children against COVID-19, implying the necessity of comprehensive assessment and health education programs for vaccination systems in China.