The social ecological model as a framework for determinants of 2009 H1N1 influenza vaccine uptake in the United States

Parents' and Caregivers' Support for in-School COVID-19 Mitigation Strategies: A Socioecological Perspective

Informed by the social ecological model, which asserts that health behaviors and beliefs are the result of multiple levels of influence, we examined factors related to parents' support for in-school COVID-19 mitigation strategies. Using data from a survey of 567 parents/caregivers of public elementary and middle school students in eight Maryland counties, we employed regression models to examine relationships between parent-, child-, family-, school-, and community-level factors and acceptability of mitigation strategies. Acceptance of COVID-19 mitigation strategies was positively correlated with child- and family-level factors, including child racial identity (parents of Black children were more accepting than those of White children, odds ratio [OR]: 2.5, 95% confidence interval [CI] = [1.5, 4.1]), parent receipt of the COVID-19 vaccine (OR: 2.4, 95% CI = [1.5, 3.7]), and parent Democrat or Independent political affiliation (compared with Republican affiliation, OR: 4.2, 95% CI = [2.6, 6.7]; OR: 2.2, 95%CI = [1.3, 3.8], respectively). Acceptance was also positively associated with parents' perceptions of their school's mitigation approach, including higher school mitigation score, indicating more intensive mitigation policies (OR: 1.1, 95% CI = [1.0, 1.1]), better school communication about COVID-19 (OR: 1.7, 95% CI = [1.4, 1.9]) and better school capacity to address COVID-19 (OR: 1.9, 95% CI = [1.5, 2.4]). Community-level factors were not associated with acceptance. Child- and parent-level factors identified suggest potential groups for messaging regarding mitigation strategies. School-level factors may play an important role in parents' acceptance of in-school mitigation strategies. Schools' capacity to address public health threats may offer an underappreciated and modifiable setting for disseminating and reinforcing public health guidance.

Disparities in Delirium across the Continuum of Care and Associations with Social Determinants of Health

Disparities exist in the identification, treatment, and management of delirium. These disparities can be most holistically and comprehensively understood by using a social-ecological model-which acknowledges multilevel impacts including individual, interpersonal, organizational, community, and policy-level factors-as well as a social determinant of health framework, that considers nonmedical factors that influence health outcomes. This narrative review leverages both frameworks to identify and discuss existing literature pertaining to the intersection of these social risk factors and delirium, focusing specifically on disparities due to racial and/or ethnic identity, language ability, and socioeconomic differences. We also look at disparities and the potential role of these social risk factors throughout the continuum of care, including prehospitalization, hospitalization, and posthospitalization factors. Understanding and analyzing the role of these inequities is critical to ensuring better health outcomes for patients at risk of and/or with delirium.

Lessons for Future Vaccination Policies: COVID-19 Vaccination Intention in People With and Without Chronic Diseases

PURPOSE

This study compared COVID-19 vaccination intentions in those with and without chronic diseases (CDs and non-CDs) in South Korea. We hypothesized that the factors associated with COVID-19 vaccination intentions would differ between CDs and non-CDs in South Korea.

METHODS

Using survey data collected through a Korean online panel in June 2021, we conducted a cross-sectional secondary data analysis. Of the 2292 participants, 411 had at least one chronic disease. To construct a comparable dataset, we selected non-CDs via a 1:1 case-control matching for age and gender. We then utilized a multivariable binary logistic regression model to explore the factors contributing to COVID-19 vaccination intentions in CDs and non-CDs.

RESULTS

All told, over 75% of participants in both groups indicated that they intended to vaccinate against COVID-19. In both groups, those who mistrusted general vaccine benefits reported significantly lower COVID-19 vaccination intentions. Regarding factors associated with vaccination intentions, CDs identified anxiety regarding coronavirus and exposure to COVID-19 vaccination promotions at the community level, while non-CDs highlighted hesitancy regarding vaccines and confidence in government/health services.

CONCLUSION

Improving vaccination acceptance will require the development and implementation of tailored approaches for CDs and non-CDs and efforts to minimize general vaccine mistrust.

Knowledge, attitudes, and intentions regarding COVID-19 vaccination in the general population and the effect of different framing messages for a brief video on intentions to get vaccinated among unvaccinated individuals in the United States during July 2021

OBJECTIVE

To identify knowledge, attitudes, and beliefs (KABs) associated with COVID-19 vaccination intentions and assess the impact of vaccine-promoting messages on vaccination intentions.

METHODS

Our nationally representative survey measured KABs of COVID-19 vaccination and incorporated a randomized experiment to assess the impact of different framing messages for a video encouraging vaccination intentions among unvaccinated adults in the US. Multivariable multinomial logistic regression models were fitted to investigate the relationships of KABs, trust in public health authorities (PHAs), and vaccine confidence with vaccination intentions. Difference-in-difference estimation was conducted to assess the impact of framing messages for a video on unvaccinated individuals' vaccination intentions.

RESULTS

We observed that people with increasingly favorable vaccine KABs, trust in PHAs, and vaccine confidence were more likely to be vaccinated or intend to get vaccinated against COVID-19. Difference-in-difference estimates indicated a positive impact of exposure to the video on vaccination intentions while framing messages in some cases appeared to lower vaccination intentions. Associations between the video and vaccination intentions were more pronounced among Black/African American and Hispanic/Latinx populations and Democrats; however, associations did not vary by trust in PHAs or vaccine confidence.

CONCLUSION

Videos that encourage people to get vaccinated may provide an efficient approach to nudge vaccine-hesitant individuals towards getting vaccinated. However, framing messages may negatively impact vaccination intentions and need to be developed carefully.

PRACTICE IMPLICATIONS

This study provides solid experimental evidence for the importance of tailoring message framing to the characteristics and experience of the audience, while cautioning potential negative impacts of framing that does not match its intended audience. Our findings are applicable to health communication strategies on the population level, such as mass media campaigns, and the use of framing for messages to encourage vaccination but may also be informative for healthcare professionals consulting hesitant individuals about COVID-19 vaccinations.

Associations Between Social Networks and COVID-19 Vaccine Uptake in 4 Rural Alabama Counties: Survey Findings

OBJECTIVES

The COVID-19 pandemic demonstrated how vaccination decisions are influenced by misinformation, disinformation, and social pressures, leading to varied and inequitable uptake rates. In this study, we examined how COVID-19 vaccine messages received via social networks were associated with vaccine uptake in rural Alabama.

METHODS

From November 2021 through March 2022, we collected 700 responses to a telephone survey administered in 4 rural Alabama counties. We asked respondents to indicate whether certain social relationships (eg, family, businesses) tried to influence them to (1) obtain or (2) avoid a COVID-19 vaccine. We used χ2 tests, Kruskal-Wallis tests, Mantel-Haenszel χ2 tests, and Fisher exact tests to examine the associations between vaccination status and survey responses.

RESULTS

Respondents in majority-African American counties were significantly more likely than those in majority-White counties to have received ≥1 dose of COVID-19 vaccine (89.8% vs 72.3%; P < .001). Respondents who received ≥1 dose had a significantly higher mean age than those who had not (58.0 vs 39.0 years; P < .001). Respondents who were encouraged to get vaccinated by religious leaders were more likely to have received ≥1 dose (P = .001), and those who were encouraged to avoid vaccination by family (P = .007), friends (P = .02), coworkers (P = .003), and health care providers (P < .001) were less likely to have received ≥1 dose. Respondents with more interpersonal relationships that encouraged them to avoid vaccination were more likely to be unvaccinated (P < .001).

CONCLUSIONS

Interpersonal relationships and demographic characteristics appeared to be important in COVID-19 vaccine decision-making in rural Alabama. Further research needs to identify how to facilitate vaccine-positive interpersonal relationships, such as peer mentoring and trusted messenger interventions.

Factors associated with vaccine hesitancy against COVID-19 among adults in Europe: a descriptive study analysis applying socio-ecological framework

OBJECTIVE

This study aimed to explore the factors associated with COVID-19 vaccine hesitancy in Europe among adults by using the Socio-Ecological Model.

RESULTS

This cross-sectional study used secondary data collected from respondents residing in 27 EU countries at the time of May 2021. The outcome was vaccine hesitancy against COVID-19, and the total sample size of 23,606 was analysed by binary logistic regression, as well as McKelvey and Zavonoia's R2. After adding each level of variables, the model found the significant and increased association with vaccine hesitancy in younger age groups (21-39 years and 40-60 years vs. 65 years+), who left full-time education at a young age (16-19 years), those with manual jobs, those with children at home, individuals residing in small towns, and beliefs related to the vaccine. Together, the levels explained 49.5% of the variance associated with vaccine hesitancy, and the addition to each variable layer increased the variance. This highlights the need to consider broad factors at multiple levels to enhance vaccine acceptance and uptake.

Different roles of interpersonal trust and institutional trust in motivating older adults to receive COVID-19 vaccines in Singapore

Since the approvals of several vaccines against COVID-19 by the World Health Organization, a large body of research has studied the determinants of individuals' intention to be vaccinated against COVID-19 in a variety of societies. Vaccine intention is a complex construct rooted in the social context that informs the decision-making process. The underlying reasons for older adults' intention to receive the vaccination is even more important to health authorities in societies with large proportions of older adults. In this paper, we interview 27 women over age 55 in Singapore about their COVID-19 vaccine decision-making. Using a social-ecological framework of trust, we identify factors at both individual and institutional levels that build or undermine trust and underlie older women's decisions to receive COVID-19 vaccinations in an authoritarian regime. Findings show that both interpersonal trust and institutional trust contribute to vaccine uptake, however, trust can also contribute to delays in vaccination. Moreover, a sizable minority of respondents report that they were vaccinated not because of institutional trust, but because they felt compelled to do so. The results shed light on directions for future vaccination campaigns.

Barriers to Family Building Among Physicians and Medical Students

Importance

Physicians and medical students who desire to build families face significant barriers due to the structure and culture of medicine.

Objective

To understand the barriers and facilitators to family building for all people in medicine-not only individuals who can become pregnant-through an open-ended, qualitative analysis of survey responses.

Design, Setting, and Participants

This qualitative study used a survey conducted in April and May 2021 with a broad sample of physicians and medical students. Participants were recruited through social media, targeting physician and medical student communities. Physicians (residents, fellows, and physicians in independent practice) and medical students of all gender identities and sexual orientations were included. Informed by a postpositivist approach, coding reliability thematic analysis was performed on 3 open-ended survey questions on family-building experiences (what they would do differently, what advice they have for others, and anything else they wished to share).

Main Outcomes and Measures

Identified themes were mapped to the social-ecological model, a model used in public health to examine how a spectrum of factors is associated with health outcomes.

Results

A total of 2025 people (1860 [92%] women; 299 [15%] Asian, 151 [8%] Black, and 1303 [64%] White; 1730 [85%] heterosexual; and 1200 [59%] physicians who had completed training) responded to at least 1 of 3 open-ended questions. Themes mapped to social-ecological model levels included: (1) cultural, eg, medical training being at odds with family building; (2) organizational, eg, lack of institutional support for the range of family-building routes; (3) interpersonal, eg, impact of social support on family building; and (4) individual, eg, socioeconomic status and other individual factors that facilitate or inhibit family building. Recommendations to improve family-building experiences include implementing family-building curricula at medical schools, providing adequate parental leave for all physicians and medical students who become parents, and providing insurance coverage for all family-building routes.

Conclusions and Relevance

In this qualitative study of physicians and medical students, self-reported barriers to family building were identified at each level of the social-ecological model. Addressing these barriers is critical to creating a more equitable family-building environment for physicians and medical students.

COVID-19 vaccination attitudes, values, intentions: US parents for their children, September 2021

OBJECTIVES

To compare vaccine-related attitudes and values of parents of children 2-17 years old to other adults, examine intentions to vaccinate their children, and identify factors associated with intending to vaccinate children.

METHODS

A nationally representative survey was conducted in September 2021 (just before the EUA for children 5-11 years old) using Ipsos KnowledgePanel, a probability-based web panel. The survey measured COVID-19 vaccination status, intentions, attitudes, values, and trust in public health authorities among US adults. Scale response options to survey items were dichotomized, and cross-tabulations and logistic regressions were performed.

RESULTS

Parents had lower odds of reporting being vaccinated against COVID-19 than other adults even after adjusting for associated sociodemographic characteristics such as age (aOR: 0.66; 95 %CI: 0.50-0.87). The most prevalent parental concerns about COVID-19 vaccines included the speed of their development (88 %), potential side effects (78 %), suspicion of government (77 %), and suspicion of pharmaceutical companies (72 %). Fewer than half (42 %) of parents intended to vaccinate their children 5-11 years old, while 38 % were uncertain and 20 % were unlikely to ever vaccinate their children. Vaccinated parents had higher odds than unvaccinated parents of intending to vaccinate their children (OR: 675.51; 95 %CI: 106.46-4286.12). Discussions with healthcare providers who encouraged COVID-19 vaccination were positively associated with intent to vaccinate children (OR: 11.29; 95 %CI: 2.60-49.02).

CONCLUSIONS

We found parental vaccination and conversations with providers were positively associated with intent to vaccinate children. Decisions about childhood vaccination need to be supported by healthcare providers and a public health system that makes vaccine access and related information equitable and accessible. Vaccination-related decision making should be guided by healthcare providers and provide information about safety and risk to children.

Attitudes toward COVID-19 and Other Vaccines: Comparing Parents to Other Adults, September 2022

Few analyses of COVID-19 vaccine attitudes also cover routine vaccines or focus on parents. In this cross-sectional study, we surveyed US adults in September 2022, immediately following the authorization of updated bivalent COVID-19 boosters for adults but before their authorization for children. The vaccine attitudes of parents were compared to other adults. Fewer parents were up-to-date on COVID-19 vaccines than other adults (54% vs. 67%), even after adjusting for age, education, and race/ethnicity (Adjusted Odds Ratio: 0.58; 95% Confidence Interval: 0.45-0.76). More parents had concerns about COVID-19 vaccines' safety in children (67% vs. 58%; aOR: 1.59; 95%CI: 1.23-2.06) and vaccine ingredients (52% vs. 45%; aOR: 1.41; 95%CI: 1.09-1.81), and more parents perceived COVID-19 in children to be no worse than a cold or the flu (51% vs. 38%; aOR: 1.56; 95%CI: 1.22-2.01). Fewer parents supported COVID-19 vaccine school requirements (52% vs. 57%; aOR: 0.75; 95%CI: 0.58-0.97) and perceived high vaccine coverage among their friends (51% vs. 61%; aOR: 0.60; 95%CI: 0.46-0.78). However, three-quarters of parents intended their child to receive all routinely recommended vaccines, whereas only half of adults intended to receive all routinely recommended vaccines themselves. To improve parental informed vaccine decision-making, public health must ensure pediatric providers have updated resources to support their discussions of vaccine risks and benefits with their patients' parents.

COVID-19 vaccine behaviour among citizens of the Métis Nation of Ontario: A qualitative study

BACKGROUND

The burden of the current COVID-19 pandemic is not shared equally in Canadian society, with Indigenous Peoples being disproportionately affected. Moreover, there is a lack of research pertaining to vaccination behaviour in Métis communities. This Métis-specific and Métis-led qualitative study endeavours to understand COVID-19 vaccine behaviour among citizens of the Métis Nation of Ontario (MNO).

METHODS

Data was collected via one-on-one interviews. Participants were recruited via the MNO's existing social media channels. Participants filled out a screening survey indicating their intention to vaccinate against COVID-19 as yes, no, or unsure. Sixteen participants (9 yes, 3 unsure, 4 no) were interviewed. Interviews averaged 30 min, and the questions and probes were developed in collaboration with the MNO. The interviewer received Métis-specific cultural safety training. Interviews were transcribed verbatim and uploaded to NVivo 12.

RESULTS

A deductive analysis using the Social Ecological Model framework (SEM) for vaccine behaviour and two blinded coders was used to understand the data. An additional factor, COVID-19 public health measures, was added to the framework to better capture the experiences of participants during the COVID-19 pandemic. Overall, the factors with the greatest number of coded references included Vaccine roll-out and availability, Organization of the public into priority groups, Public discourse, Interpersonal influences, Interface with health professionals, Knowledge state, Trust, and Vaccine risk perception. Bandwagoning (following others' behaviour) and Freeloading (perceiving enough people have been vaccinated), both factors of the SEM, were not discussed. Yes, no, and unsure participant groups were compared to understand the influences of each factor based on COVID-19 vaccination intention.

CONCLUSIONS

MNO citizens COVID-19 vaccine behaviour was negatively and positively influenced by a number of factors. This information will allow the MNO and public health units to better tailor their messaging for COVID-19 vaccine uptake campaigns and future pandemic emergencies.

Attitudes and Values of US Adults Not Yet Up-to-Date on COVID-19 Vaccines in September 2022

(1) Background: Periodic resurgences in COVID-19 due to more contagious variants highlight the need to increase coverage of booster doses. (2) Methods: Our September 2022 nationally representative survey of US adults measured COVID-19 vaccination status, intentions, attitudes, values, and confidence in information sources. (3) Findings: Although 85% of the weighted sample reported receiving at least one dose of a COVID-19 vaccine, only 63% reported being up-to-date on COVID-19 vaccines (e.g., received a booster dose). Only 12% of those not yet up-to-date indicated they were likely to get up-to-date as soon as possible, whereas 42% were unlikely to ever get up-to-date, and 46% were still uncertain. Most of those not up-to-date on their COVID-19 vaccines were under 45 years of age (58%), without a bachelor's degree (76%), making under $75,000 annually (53%), and Republican or Independent (82%). Prevalent concerns about COVID-19 vaccines among those uncertain about getting up-to-date included: potential side effects that have not been figured out yet (88%), speed of development (77%), newness (75%), ingredients (69%), drug companies making money (67%), allergic reactions (65%), and experimenting on people (63%). (4) Conclusions: Nearly half of adults not yet up-to-date on COVID-19 vaccines were uncertain about doing so, indicating an opportunity to support their decision-making.

Immunization of Solid Organ Transplant Candidates and Recipients: A 2022 Update

Immunizations are a relatively safe and cost-effective intervention to prevent morbidity and mortality associated with vaccine preventable infection (VPIs). As such, immunizations are a critical part of the care of pre and posttransplant patients and should be prioritized. New tools are needed to continue to disseminate and implement the most up-to-date vaccine recommendations for the SOT population. These tools will help both primary care providers and multi-disciplinary transplant team members taking care of transplant patients to stay abreast of evidence-based best practices regarding the immunization of the SOT patient.

Reducing barriers to COVID-19 vaccine uptake through a culturally sensitive pharmacy-led patient medication education group in a behavioral health population

BACKGROUND

Hesitancy surrounding the coronavirus disease 2019 (COVID-19) vaccine is high in those with mental illnesses owing to intrapersonal barriers and barriers relating to social determinants of health.

OBJECTIVES

This study describes the implementation of a pharmacy-driven, culturally sensitive education program focused on COVID-19 vaccine hesitancy.

METHODS

This was an institutional review board-exempt, descriptive, quality improvement study held at a behavioral health facility. An education program dedicated to reduce COVID-19 vaccine hesitancy was developed. Each educator completed training on providing culturally sensitive care to behavioral health patients. Patients voluntarily attended pharmacist-led patient medication education groups (PMEGs) and were offered an anonymous survey. Participation was documented in the electronic health record (EHR). Vaccination status and perception of the education were collected through retrospective analysis of the EHR, survey results, and state COVID-19 vaccine registry.

RESULTS

Twenty PMEGs were provided and reached 90 individuals, with 47% identifying as black, indigenous, or person of color. Sixty of 90 patients received at least 1 vaccine. For participants who were eligible for a second dose of a 2-dose series, 62% completed their second vaccination after PMEGs. Vaccination rates were highest in white participants (73.9%) followed by 64.7% of black participants, both higher than state specific rates. Participants self-reported an increase in their likelihood to become vaccinated after PMEG attendance on surveys and rated the quality of education as high.

CONCLUSION

Patients who experience vaccine hesitancy had the opportunity to address their concerns on the COVID-19 vaccine. Overall, the program was well received and positively affected the patient's likelihood of obtaining and completing vaccination against COVID-19.

Israeli parents` views on coronavirus (COVID-19) vaccinations for children: A cross-sectional study

BACKGROUND

Parents play the decisive role in children's vaccination. Our study aimed as assessing attitudes of parents toward the COVID-19 vaccine for children aged 5-18 and to define sources of influence on these attitudes, the barriers and reasons for hesitation.

METHODS

In this cross-sectional study, 138 Israeli parents of 5-18 aged children completed a self-administered structured questionnaire.

FINDINGS

More than a quarter of parents reported that they did not intend to vaccinate their children. Independent of other demographic characteristics, parents who do not vaccinate their children accordingly to the routine vaccinations have five-fold significant odds not to vaccinate with COVID-19 vaccine (OR = 4.8, 95% CI: 1.8-12.7). Greater social influence was significantly and negatively associated with intentions not to vaccinate a child. Among parents who do not intend to vaccinate their children, the most frequent reasons were fear of possible side effects (92%), vaccine novelty (92%) and lack of belief in its effectiveness (69%).

DISCUSSION

This study found that vaccination in the past as part of routine government immunization programs predict a tendency to vaccinate children during the pandemic. Among the factors associated with the intention not to vaccinate, concerns and uncertainty about the necessity of the vaccine, its side effects and reliability have been emphasized.

APPLICATION TO PRACTICE

Cultural-religious adjustments should be applied when implementing interventions aiming to promote vaccination in routines and emergencies. Social influence is important in adopting a positive attitude toward vaccines. Public health professionals should incorporate those parents who have vaccinated their children and have a positive attitude toward vaccination.

Multi-method findings on COVID-19 vaccine acceptability among urban refugee adolescents and youth in Kampala, Uganda

ABSTRACTScant studies have explored COVID-19 vaccine acceptability among refugees. However, contexts of forced migration may elevate COVID-19 vulnerabilities, and suboptimal refugee immunisation rates are reported for other vaccine-preventable diseases. We conducted a multi-methods study to describe COVID-19 vaccine acceptability among urban refugee youth in Kampala, Uganda. This study uses cross-sectional survey data from a cohort study with refugees aged 16-24 in Kampala to examine socio-demographic factors associated with vaccine acceptability. A purposively sampled cohort subset (n = 24) participated in semi-structured in-depth individual interviews, as did key informants (n = 6), to explore COVID-19 vaccine acceptance. Among 326 survey participants (mean age: 19.9; standard deviation 2.4; 50.0% cisgender women), vaccine acceptance was low (18.1% reported they were very likely to accept an effective COVID-19 vaccine). In multivariable models, vaccine acceptance likelihood was significantly associated with age and country of origin. Qualitative findings highlighted COVID-19 vaccine acceptability barriers and facilitators spanning social-ecological levels, including fear of side effects and mistrust (individual level), misinformed healthcare, community and family attitudes (community level), tailored COVID-19 services for refugees (organisational and practice setting), and political support for vaccines (policy environment). These data signal the urgent need to address social-ecological factors shaping COVID-19 vaccine acceptability among Kampala's young urban refugees.Trial registration: ClinicalTrials.gov identifier: NCT04631367.

Food behaviours and eating habits among Sub-Saharan African migrant mothers of school-aged children in South Australia

Overweight, obesity and chronic conditions like diabetes, stroke and heart disease represent a significant burden to public health. Traditional foods and healthy dietary habits can reduce the risk of these conditions. Therefore, this study aimed to explore traditional food patterns and eating habits among Sub-Saharan African migrant mothers of school-aged children in South Australia. The study was a qualitative inquiry that used face-to-face interviews with 15 mothers of school-aged children in South Australia. Snowballing was used to sample participants, and data were audio-recorded, transcribed verbatim, coded, and analysed thematically. Four broad themes described participants' food behaviours and eating habits, including maintaining traditional food patterns, changes in traditional food patterns and eating habits, concerns with food environments in Australia, and challenges with traditional food availability and access in Australia. This study found that although mothers were committed to maintaining their traditional foods, they found it increasingly difficult to continue such habits. Participants reported challenges as their children are increasingly demanding westernised foods. While some parents pushed back against such demands from their children, others felt helpless and relented. Some views showed that food environments, food systems, access, and scarcity of traditional foods in Australia influenced the participants' food patterns and eating habits. Appropriately tailored healthy eating health promotion actions targeting school-aged children and mothers in this population need to consider their food contexts. Promoting the use of traditional foods, their preparation practices, and processing might be helpful in this community when developing healthy eating programs.

Racial/ethnic disparities in influenza risk perception and vaccination intention among Pima County residents in Arizona

While influenza cases in Arizona have nearly tripled since 2018, vaccination rates continue to lag. Statewide, Hispanics and African Americans had the lowest vaccination rates despite having higher influenza infection rates than Whites. Given Arizona's racial influenza vaccination disparity and the general increase in vaccination hesitancy due to COVID-19, the purpose of this study was to better understand the influences of seasonal influenza vaccination in Arizona during the COVID-19 pandemic using qualitative methods. Findings from this study revealed that many participants were motivated to get the influenza vaccine to protect their family and close friends. The heightened concern for COVID-19 prompted some Hispanic/Latino focus group discussion participants to consider getting vaccinated. However, many Hispanic/Latino participants also expressed that they stopped getting influenza vaccine due to negative vaccination experiences or concern about sickness following immunization. African American participants primarily discussed receiving the vaccine as part of their routine health visit. Compared to other races, more White participants believed that vaccination was unimportant because they were healthy, and the people they interacted with never got sick. Distinct factors influence risk perception and vaccination intention across different racial/ethnic groups. Effective interventions can account for these factors and be tailored to the target population to maximize vaccination uptake.

Perceived Vaccine Availability and the Uptake of Measles Vaccine in Sudan: The Mediating Role of Vaccination Hesitancy

This study aimed to evaluate whether measles vaccine uptake can be predicted directly or indirectly by parental perceptions about the availability of measles vaccine services with parental hesitancy towards the measles vaccine as a potential mediator. This was a community-based cross-sectional study conducted at Omdurman locality in Khartoum state, Sudan in February 2019. The study population included parents/guardians having at least one child aged 2-3 years old. Mediation analysis was conducted using two models, the ordinary least squares path analysis and multiple logistic regression. These models considered perceived vaccine accessibility and availability as independent factors, vaccine uptake as dependent factors, and vaccine hesitancy (PACV scores) as a mediator. A total of 495 responded and the mean age of the mothers who participated in the study was 31.1 (SD = 5.73). Half of the respondents (50.1%) completed university education and nearly three-quarters of the respondents (74.7%) were housewives. After controlling for the other factors, including the mother's age and the number of children, parental perception about the accessibility and availability of the measles vaccine influences the uptake of the measles vaccine indirectly through the mediation effect of measles vaccine hesitancy. We suggest that intervening in measles vaccine hesitancy in addition to measles vaccination access issues will have a positive impact on the uptake and coverage of the measles vaccine in Sudan.

A social ecological approach to identify the barriers and facilitators to COVID-19 vaccination acceptance: A scoping review

BACKGROUND

COVID-19 is an infectious disease caused by the SARS-CoV-2 virus that has caused substantial impact on population health, healthcare, and social and economic systems around the world. Several vaccines have been developed to control the pandemic with varying effectiveness and safety profiles. One of the biggest obstacles to implementing successful vaccination programmes is vaccine hesitancy stemming from concerns about effectiveness and safety. This review aims to identify the factors influencing COVID-19 vaccine hesitancy and acceptance and to organize the factors using the social ecological framework.

METHODS

We adopted the five-stage methodological framework developed by Arksey and O'Malley to guide this scoping review. Selection criteria was based on the PICo (Population, Phenomenon of interest and Context) framework. Factors associated with acceptance and hesitancy were grouped into the following: intrapersonal, interpersonal, institutional, community, and public policy factors using the social ecological framework.

RESULTS

Fifty-one studies fulfilled this review's inclusion criteria. Most studies were conducted in Europe and North America, followed by Asia and the Middle East. COVID-19 vaccine acceptance and hesitancy rates varied across countries. Some common demographic factors associated with hesitancy were younger age, being female, having lower than college education, and having a lower income level. Most of the barriers and facilitators to acceptance of the COVID-19 vaccines were intrapersonal factors, such as personal characteristics and preferences, concerns with COVID-19 vaccines, history/perception of general vaccination, and knowledge of COVID-19 and health. The remaining interpersonal, institution, community, and public policy factors were grouped into factors identified as barriers and facilitators.

CONCLUSION

Our review identified barriers and facilitators of vaccine acceptance and hesitancy and organised them using the social ecological framework. While some barriers and facilitators such as vaccine safety are universal, differentiated barriers might exist for different target groups, which need to be understood if they are to be addressed to maximize vaccine acceptance.

The influence of social norms varies with "others" groups: Evidence from COVID-19 vaccination intentions

The theory that health behaviors spread through social groups implies that efforts to control COVID-19 through vaccination will succeed if people believe that others in their groups are getting vaccinated. But "others" can refer to many groups, including one's family, neighbors, fellow city or state dwellers, or copartisans. One challenge to examining these understudied distinctions is that many factors may confound observed relationships between perceived social norms (what people believe others do) and intended behaviors (what people themselves will do), as there are plausible common causes for both. We address these issues using survey data collected in the United States during late fall 2020 (n = 824) and spring 2021 (n = 996) and a matched design that approximates pair-randomized experiments. We find a strong relationship between perceived vaccination social norms and vaccination intentions when controlling for real risk factors (e.g., age), as well as dimensions known to predict COVID-19 preventive behaviors (e.g., trust in scientists). The strength of the relationship declines as the queried social group grows larger and more heterogeneous. The relationship for copartisans is second in magnitude to that of family and friends among Republicans but undetectable for Democrats. Sensitivity analysis shows that these relationships could be explained away only by an unmeasured variable with large effects (odds ratios between 2 and 15) on social norms perceptions and vaccination intentions. In addition, a prediction from the "false consensus" view that intentions cause perceived social norms is not supported. We discuss the implications for public health policy and understanding social norms.

Trust in Science as a Possible Mediator between Different Antecedents and COVID-19 Booster Vaccination Intention: An Integration of Health Belief Model (HBM) and Theory of Planned Behavior (TPB)

As the literature highlights, many health behavior theories try to explain both social and psychological variables influencing an individual’s health behavior. This study integrates insights relative to the antecedents of getting vaccinated from health behavior theories, particularly including the health belief model (HBM), the theory of planned behavior (TPB), and the different socio-demographic factors. Furthermore, we considered the possible mechanism of impact of distrust in science on individuals’ hesitance and resistance to taking up SARS-CoV-2 vaccination in subjects living in Italy. A correlational study of 1095 subjects enrolled when the national vaccination campaign for the third dose was launched. A questionnaire was used to measure: Italian Risk Perception; subjective norm; trust in science, trust in the vaccine; fear of COVID-19; fear of the vaccine; perceived knowledge about SARS-CoV-2; booster vaccination intention. Principal results show that: (i) the positive relationship provided by HBM theory between perceptions of SARS-CoV-2 risk (vulnerability and severity) and intention to have the vaccine, through fear of COVID-19; (ii) the positive relationship between subjective norms and both trust in science and vaccination intention; (iii) that trust in science plays a crucial role in predicting vaccination intention. Finally, the results provided indications about a positive relationship between subjective norms and fear of COVID-19, and a full mediation role of trust in science in the relationships between determinants of both TPA and HBM, fear of COVID-19, and vaccination intention. In conclusion, an individual’s intention (not) to get vaccinated requires the consideration of a plethora of socio-psychological factors. However, overall, trust in science appears to be a key determinant of vaccination intention. Additional strategies promoting healthy behavior are needed.

COVID-19 Vaccination Status, Attitudes, and Values among US Adults in September 2021

Background: The Delta COVID-19 variant caused a resurgence in cases and deaths during the summer of 2021, particularly among the unvaccinated, highlighting the need to increase vaccine coverage. We describe a survey conducted in September 2021, in the midst of the Delta variant surge, after the FDA fully approved Pfizer-BioNTech’s vaccine for ages 16+ and issued an emergency use authorization for ages 12−15. Methods and Findings: US adults were surveyed to measure COVID-19 vaccination status, intentions, attitudes, values, and trust in public health authorities. More than three-quarters (77%) reported receiving at least one dose of COVID-19 vaccination. Of the unvaccinated, 6% intended to vaccinate, 40% were unlikely to ever vaccinate, and 55% remained uncertain. Most of the unvaccinated were <45 years old (62%), without a bachelor’s degree (83%), earning less than $85,000 annually (74%), and Republican/Independent (66%). Concerns among the unvaccinated-yet-still-uncertain included the vaccines’ safety (86%), speed of development (86%), and suspicion of government (79%) and pharmaceutical companies (69%). Most (86%) of the unvaccinated reported they would not vaccinate if mandated by their employer. About one third (34%) of the unvaccinated reported facing at least one barrier to vaccination. Conclusion: More than half of unvaccinated adults remained uncertain about COVID-19 vaccination, indicating an opportunity to support their decision making. Public health must increase easy and equitable access to vaccination and renew efforts to provide unvaccinated populations access to information from trusted sources.

Socio-Ecological Factors and Well-Being among Self-Employed in Europe during the COVID-19 Pandemic

BACKGROUND

The self-employed are at increased risk of negative well-being outcomes when facing adversity such as the COVID-19 pandemic. Studies that examine socio-ecological factors that may protect their well-being are warranted.

METHODS

Data were drawn from a cross-sectional survey of European self-employed people (n = 1665). The WHO-5 Well-being Index was used to examine the impact on well-being of factors at four socio-ecological levels. Independent sample t-tests, Pearson correlations and linear regression were applied to analyse differences between groups of self-employed and interactions between variables using SPSS.

RESULTS

Well-being and the socio-ecological factors of resilience, social support, useful work and finding the rules clear were positively correlated with well-being. For self-employed who reported that it was challenging to run their business during the pandemic, social support and finding rules clear were of significantly greater importance to their well-being.

CONCLUSIONS

The findings highlight that the socio-ecological factors of resilience, social support, doing useful work and finding the rules clear affect well-being. The results also indicate that it is vital to consider factors at multiple socio-ecological levels to improve the well-being of the self-employed during adversity.

A socio-ecological perspective on parents' intentions to vaccinate their children against COVID-19

INTRODUCTION

Vaccinating children against COVID-19 protects children's health and can mitigate the spread of the virus to other community members.

OBJECTIVE

The primary objective of this study was to use a socio-ecological perspective to identify multi-level factors associated with US parents' intention to vaccinate their children.

METHODS

This study used a longitudinal online cohort. Multinomial logistic regression models assessed socio-ecological predictors of negative and uncertain child COVID-19 vaccination intentions compared to positive intentions.

RESULTS

In June 2021, 297 parents were surveyed and 44% reported that they intended to vaccinate their children while 25% expressed uncertainty and 31% did not intend to vaccinate their children. The likelihood of reporting uncertain or negative intention, compared to positive intention to vaccinate their children was higher among parents who had not received a COVID-19 vaccination and those who did not have trusted information sources. Parents who talked to others at least weekly about the COVID-19 vaccine were less likely to endorse uncertain compared to positive vaccine intentions (aRRR: 0.44; 95% CI: 0.20-0.93). A sub-analysis identified that parents had significantly higher odds of intending to vaccinate older children compared to younger children (children ages 16-17 years v. 0-4 years OR: 2.01, 95% CI: 1.05-3.84). An additional sub-analysis assessed the stability of parents' intention to vaccinate their children between March 2021 and June 2021 (N=166). There was transition within each intention group between the study periods; however, symmetry and marginal homogeneity test results indicated that the shift was not statistically significant. Parents expressing uncertainty in March 2021 were the most likely to change their intention, with 24% transitioning to positive intention and 23% to negative intention in June 2021.

CONCLUSION

Study findings suggest that programs to promote vaccination uptake should be dyadic and work to promote child and parent vaccination. Peer diffusion strategies may be particularly effective at promoting child vaccination uptake among parents expressing uncertainty.

A Socio-Ecological Framework for Cancer Prevention in Low and Middle-Income Countries

Cancer incidence and mortality rates continue to rise globally, a trend mostly driven by preventable cancers occurring in low-and middle-income countries (LMICs). There is growing concern that many LMICs are ill-equipped to cope with markedly increased burden of cancer due to lack of comprehensive cancer control programs that incorporate primary, secondary, and tertiary prevention strategies. Notably, few countries have allocated budgets to implement such programs. In this review, we utilize a socio-ecological framework to summarize primary (risk reduction), secondary (early detection), and tertiary (treatment and survivorship) strategies to reduce the cancer burden in these countries across the individual, organizational, community, and policy levels. We highlight strategies that center on promoting health behaviors and reducing cancer risk, including diet, tobacco, alcohol, and vaccine uptake, approaches to promote routine cancer screenings, and policies to support comprehensive cancer treatment. Consistent with goals promulgated by the United Nations General Assembly on Noncommunicable Disease Prevention and Control, our review supports the development and implementation of sustainable national comprehensive cancer control plans in partnership with local communities to enhance cultural relevance and adoption, incorporating strategies across the socio-ecological framework. Such a concerted commitment will be necessary to curtail the rising cancer and chronic disease burden in LMICs.

Understanding the societal factors of vaccine acceptance and hesitancy: evidence from Hong Kong

OBJECTIVES

Vaccination is considered to be an important public health strategy for controlling the COVID-19 pandemic. Besides subjective evaluations of the vaccine and the health threat, societal factors have been seen as crucial to vaccination decisions. Based on a socioecological perspective, this study examines the role of societal factors in COVID-19 vaccine hesitancy in Hong Kong.

STUDY DESIGN AND METHOD

An online survey was fielded between 25 and 28 June 2021, collecting 2753 complete responses. Multinomial logistic regression was conducted to examine how subjective evaluations of the vaccine (summarised by the 5C model - Confidence, Collective responsibility, Constraints, Complacency and Calculation), threat perception, interpersonal influences and institutional trust contribute to explaining three types of decision - acceptant (vaccinated, scheduled or indicated 'Yes'), hesitant (unvaccinated and indicated 'Maybe' on intention) and resistant (unvaccinated and indicated 'No').

RESULTS

A total of 43.2%, 21.7% and 35.1% of respondents were acceptant, hesitant and resistant. Although the 5C model remained useful in explaining vaccination decisions, respondents were heavily influenced by the decisions of their family, although they were less influenced by friends. Second, respondents tended to accept the vaccine when they had a weaker perception that the act is supportive of the government and were less resistant if they had stronger institutional trust.

CONCLUSION

Under the low-incidence and low-trust environment such as Hong Kong, vaccination decisions are heavily influenced by family's decision and the perception of vaccination as socially and politically desirable. Our findings highlight the importance of a nuanced conception of interpersonal and political influence towards vaccine acceptance/hesitancy.

The Impact and Vaccination Coverage of Seasonal Influenza among Children Aged 6-59 Months in China in 2017-2018: An Internet Panel Survey

Seasonal influenza vaccination is highly recommended for 6-59-month-old children. To determine the impact of seasonal influenza and the factors affecting influenza vaccine uptake among children, we conducted an opt-in Internet panel survey of parents from 21 March 2018 to 1 April 2018. Overall, 40.5% (1913/4719) of children experienced influenza-like illness (ILI), 92.4% of parents sought medical care for children with ILI (outpatients: 61.2%, inpatients: 12.8%), 39.6% of parents preferred to take their sick child to a tertiary hospital, and 57.3% of family members requested leave to care for children with ILI. There was a median of three days of absenteeism (2, 5) per sick child, and 39.4% of children received the influenza vaccine during the 2017-2018 influenza season. Vaccine coverage among children aged 6-11 months and 48-59 months was lower than that among 12-47-month-old children. The top three reasons for not vaccinating were: the influenza vaccine was not recommended by healthcare workers (21.1%), no knowledge about the influenza vaccine (19.2%), and lack of confidence in the vaccine's effectiveness (14.3%). Our findings highlight the need for awareness about the severity of influenza, hygiene behavior, and effectiveness of the influenza vaccine among children and their family members in China.

Racial and Ethnic Disparities in Adult Vaccination: A Review of the State of Evidence

Background

Adult vaccination coverage remains low in the United States, particularly among racial and ethnic minority populations.

Objective

To conduct a comprehensive literature review of research studies assessing racial and ethnic disparities in adult vaccination.

Search Methods

We conducted a search of PubMed, Cochrane Library, ClinicalTrials.gov, and reference lists of relevant articles.

Selection Criteria

Research studies were eligible for inclusion if they met the following criteria: (1) study based in the United States, (2) evaluated receipt of routine immunizations in adult populations, (3) used within-study comparison of race/ethnic groups, and (4) eligible for at least one author-defined PICO (patient, intervention, comparison, and outcome) question.

Data Collection and Analysis

Preliminary abstract review was conducted by two authors. Following complete abstraction of articles using a standardized template, abstraction notes and determinations were reviewed by all authors; disagreements regarding article inclusion/exclusion were resolved by majority rule. The Social Ecological Model framework was used to complete a narrative review of observational studies to summarize factors associated with disparities; a systematic review was used to evaluate eligible intervention studies.

Results

Ninety-five studies were included in the final analysis and summarized qualitatively within two main topic areas: (1) factors associated with documented racial-ethnic disparities in adult vaccination and (2) interventions aimed to reduce disparities or to improve vaccination coverage among racial-ethnic minority groups. Of the 12 included intervention studies, only 3 studies provided direct evidence and were of Level II, fair quality; the remaining 9 studies met the criteria for indirect evidence (Level I or II, fair or poor quality).

Conclusions

A considerable amount of observational research evaluating factors associated with racial and ethnic disparities in adult vaccination is available. However, intervention studies aimed at reducing these disparities are limited, are of poor quality, and insufficiently address known reasons for low vaccination uptake among racial and ethnic minority adults.

Factors Associated with Health Inequalities in Infectious Disease Pandemics Predating COVID-19 in the United States: A Systematic Review

Objective

Previous pandemics may offer evidence on mediating factors that contributed to disparities in infection and poor outcomes, which could inform the effort to mitigate potential unequal outcomes during the current COVID-19 pandemic. This systematic review sought to examine those factors.

Methods

We searched MEDLINE, PsycINFO, and Cochrane to May 2020. We included studies examining health disparities in adult U.S. populations during infectious disease epidemics or pandemics. Two investigators screened abstracts and full text. We assessed study quality using the Newcastle/Ottawa Scale or the Critical Appraisal Skills Programme Checklist for Qualitative Studies.

Results

Sixteen articles were included, of which 14 focused on health disparities during the 2009 H1N1 influenza pandemic. Studies showed that disparities during the H1N1 pandemic were more related to differential exposure to the virus than to susceptibility or access to care. Overall, pandemic-related disparities emanate primarily from inequalities in social conditions that place racial and ethnic minorities and low socioeconomic status populations at greater risk of exposure and infection, rather than individual-level factors such as health behaviors and comorbidities.

Conclusions

Policy- and systems-level interventions should acknowledge and address these social determinants of heightened risk, and future research should evaluate the effects of such interventions to avoid further exacerbation of health inequities during the current and future pandemics.

Vaccine Hesitancy among Parents and Its Association with the Uptake of Measles Vaccine in Urban Settings in Khartoum State, Sudan

Vaccine uptake is one of the indicators that has been used to guide immunization programs. This study aimed to evaluate whether measles vaccine uptake is predicted by measles vaccine hesitancy. A community-based cross-sectional study was conducted in urban districts in Khartoum state in February 2019. Measles vaccine uptake among children was measured as either fully vaccinated or partially/not vaccinated. The Parent Attitudes about Childhood Vaccines (PACV) scale was used to measure measles vaccine hesitancy. Multivariate logistic regression was run to identify the predictors of measles vaccination uptake, controlling for sociodemographic variables, and the adjusted odds ratios (aORs) with 95% CI were calculated. The receiver operator characteristic (ROC) curve was created, and the area under the curve (AUC) for the PACV was computed. Data were collected from 495 participants. We found that measles vaccine hesitancy (PACV scores) predicts the uptake of measles vaccine after controlling for other potential social confounders, such as the mother's age and the number of children (aOR 1.055; 95% CI 1.028-1.028). Additionally, the ROC for the PACV yielded an area under the curve (AUC 0.686 (95% CI 0.620-0.751; p < 0.001)). Our findings show that measles vaccine hesitancy in Sudan directly influences the uptake of the measles vaccine. Addressing the determinants of vaccine hesitancy through communication strategies will improve vaccine uptake.

Shifting the Demand for Vaccines: A Review of Strategies

Vaccines prevent millions of deaths, and yet millions of people die each year from vaccine-preventable diseases. The primary reason for these deaths is that a significant fraction of the population chooses not to vaccinate. Why don't people vaccinate, and what can be done to increase vaccination rates besides providing free and easy access to vaccines? This review presents a conceptual framework, motivated by economic theory, of which factors shift the demand for vaccines. Next, it critically examines the literature on these demand shifters and interventions that target these demand shifters. The review concludes with offering directions for future research and lessons for public health decision-making. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

A social media microinfluencer intervention to reduce coronavirus disease 2019 vaccine hesitancy in underserved Tennessee communities: A protocol paper

Background

Central to effective public health policy and practice is the trust between the population served and the governmental body leading health efforts, but that trust has eroded in the years preceding the pandemic. Vaccine hesitancy among adults is also a growing concern across the United States. Recent data suggest that the trustworthiness of information about the coronavirus 2019 (COVID-19) vaccine was a larger concern than the vaccine’s adverse effects or risks.

Objective

This study aims to describe the methods used to create a public health microinfluencer social media vaccine confidence campaign for the COVID-19 vaccine in underserved Tennessee communities. A secondary objective is to describe how the Social-Ecological Model (SEM) and Social Cognitive Theory may address vaccine hesitancy using community pharmacies.

Methods

In late 2020, 50 independent community pharmacies in underserved communities across Tennessee were involved in a public health project with the State of Tennessee Department of Health and the University of Tennessee Health Science Center College of Pharmacy. The project involved a 3-pronged, pharmacy-based COVID-19 vaccination outreach project, including (1) social media messaging (i.e., microinfluencer approach), (2) community partner collaboration, and (3) in-pharmacy promotion. Quantitative and qualitative data will assess the quality and effectiveness of the program. Social media outcomes will also be assessed to measure the impact of the microinfluencer social media training.

Results

Project implementation is planned for 6 months (January 2021 to June 2021) after an initial month of planning by the research team (December 2020) and preceding several months of assessment (July 2021 and beyond).

Conclusions

Novel, theory-based approaches will be necessary to improve vaccine confidence. One approach to promoting public health, derived from the SEM, may be to use trusted microinfluencers on social media platforms, such as local community pharmacists and community leaders.

Population Vulnerability to the SARS-CoV-2 Virus Infection. A County-Level Geographical-Methodological Approach in Romania

The assessment and identification of risk/vulnerable groups and risk factors are vital elements that can help quantify the pandemic potential of the SARS-CoV-2 virus in order to plan prevention and treatment measures. The aim of the study is to identify a methodological approach of population vulnerability to the SARS-CoV-2 virus infection. The study identifies reliable data sources and sets up a unitary database with statistical variables, quantitative and qualitative indicators with potential for being updated and improved. The analysis takes into account a number of variables/indicators (e.g., elderly persons, population without physician care, number of people suffering from cardiovascular diseases, number of people suffering from respiratory diseases, dwellings not connected to the public water supply network, no. of medical staff, number of COVID-19 hospitals, PCR testing laboratories, number of vaccinated persons) grouped into the key vulnerability components: exposure, sensitivity, coping capacity and adaptive capacity. They allowed the computation of the final Index of Population Vulnerability to the SARS-CoV-2 virus infection and the mapping of different dimensions of vulnerability. The study was performed using the statistical data available at NUTS3/County level provided by different institutions (e.g., the Ministry of Health, the National Institute of Public Health, the Strategic Communication Group, and the National Institute of Statistics). The mapping of the different degrees of vulnerability could solve a problem of visibility for possible areas with vulnerable population, but also a problem of communication between different institutional health and administrative levels, as well as between all of them and the local communities and/or professionals.

Facilitators and Barriers to Providing Vaccinations During Hospital Visits

BACKGROUND

Many children are undervaccinated at the time of hospital admission. Our objective was to explore the facilitators and barriers to vaccinating during hospitalization.

METHODS

We conducted qualitative interviews of parents, primary care pediatricians, emergency department (ED) physicians, and pediatric hospitalists. Parents of undervaccinated hospitalized children who were admitted through the ED were invited to participate. We used purposive sampling to identify physician participants. Semistructured interviews querying participants' perspectives on hospital-based vaccination were audiorecorded and transcribed. Parent demographics and physician practice characteristics were collected. Transcripts were analyzed for facilitators and barriers to vaccinating during acute hospital visits by using inductive content analysis. A conceptual framework was developed on the basis of the social ecological model.

RESULTS

Twenty-one parent interviews and 10 physician interviews were conducted. Of parent participants, 86% were female; 76% were white. Physician participants included 3 primary care pediatricians, 3 ED physicians, and 4 hospitalists. Facilitators and barriers fell under 4 major themes: (1) systems-level factors, (2) physician-level factors, (3) parent-provider interactional factors, and (4) parent- and child-level factors. Parent participants reported a willingness to receive vaccines during hospitalizations, which aligned with physician participants' experiences. Another key facilitator identified by parent and physician participants was the availability of shared immunization data. Identified by parent and physician participants included the availability of shared immunization data. Barriers included being unaware that the child was vaccine-eligible, parental beliefs against vaccination, and ED and inpatient physicians' perceived lack of skills to effectively communicate with vaccine-hesitant parents.

CONCLUSIONS

Parents and physicians identified several key facilitators and barriers to vaccinating during hospitalization. Efforts to provide inpatient vaccines need to address existing barriers.

The Roles of General Health and COVID-19 Proximity in Contact Tracing App Usage: Cross-sectional Survey Study

Background

Contact tracing apps are considered useful means to monitor SARS-CoV-2 infections during the off-peak stages of the COVID-19 pandemic. Their effectiveness is, however, dependent on the uptake of such COVID-19 apps.

Objective

We examined the role of individuals’ general health status in their willingness to use a COVID-19 tracing app as well as the roles of socioeconomic characteristics and COVID-19 proximity.

Methods

We drew data from the WageIndicator Foundation Living and Working in Coronavirus Times survey. The survey collected data on labor market status as well as the potential confounders of the relationship between general health and COVID-19 tracing app usage, such as sociodemographics and regular smartphone usage data. The survey also contained information that allowed us to examine the role of COVID-19 proximity, such as whether an individual has contracted SARS-CoV-2, whether an individual has family members and colleagues with COVID-19, and whether an individual exhibits COVID-19 pandemic–induced depressive and anxiety symptoms. We selected data that were collected in Spain, Italy, Germany, and the Netherlands from individuals aged between 18 and 70 years (N=4504). Logistic regressions were used to measure individuals’ willingness to use a COVID-19 tracing app.

Results

We found that the influence that socioeconomic factors have on COVID-19 tracing app usage varied dramatically between the four countries, although individuals experiencing forms of not being employed (ie, recent job loss and inactivity) consistently had a lower willingness to use a contact tracing app (effect size: 24.6%) compared to that of employees (effect size: 33.4%; P<.001). Among the selected COVID-19 proximity indicators, having a close family member with SARS-CoV-2 infection was associated with higher contact tracing app usage (effect size: 36.3% vs 27.1%; P<.001). After accounting for these proximity factors and the country-based variations therein, we found that having a poorer general health status was significantly associated with a much higher likelihood of contact tracing app usage; compared to a self-reported “very good” health status (estimated probability of contact tracing app use: 29.6%), the “good” (estimated probability: +4.6%; 95% CI 1.2%-8.1%) and “fair or bad” (estimated probability: +6.3%; 95% CI 2.3%-10.3%) health statuses were associated with a markedly higher willingness to use a COVID-19 tracing app.

Conclusions

Current public health policies aim to promote the use of smartphone-based contact tracing apps during the off-peak periods of the COVID-19 pandemic. Campaigns that emphasize the health benefits of COVID-19 tracing apps may contribute the most to the uptake of such apps. Public health campaigns that rely on digital platforms would also benefit from seriously considering the country-specific distribution of privacy concerns.

Sub-national disparities in accessing anti-malarial drug treatment in eastern Indonesia

BACKGROUND

Poor access to health care providers was among the contributing factors to less prompt and ineffective malaria treatment. This limitation could cause severe diseases in remote areas. This study examined the sub-national disparities and predictors in accessing anti-malarial drug treatment among adults in Eastern Indonesia.

METHODS

The study analyzed a subset of the 2018 National Basic Health Survey conducted in all 34 provinces in Indonesia. We extracted socio-demographic data of 4655 adult respondents diagnosed with malaria in the past 12 months in five provinces in Eastern Indonesia. The association between socio-demographic factors and the access to anti-malarial drug treatment was assessed using logistic regression.

RESULTS

Over 20% of respondents diagnosed with malaria within last 12 months admitted that they did not receive anti-malarial drug treatment (range 12-29.9%). The proportion of untreated cases was 12.0% in East Nusa Tenggara, 29.9% in Maluku, 23.1% in North Maluku, 12.7% in West Papua, and 15.6% in Papua. The likelihood of receiving anti-malarial drug treatment was statistically lower in Maluku (adjusted OR = 0.258; 95% CI 0.161-0.143) and North Maluku (adjusted OR = 0.473; 95% CI 0.266-0.840) than those in Eastern Nusa Tenggara (reference). Urban respondents were less likely to receive malaria treatment than rural (adjusted OR = 0.545; 95% CI 0.431-0.689).

CONCLUSIONS

This study found that there were sub-national disparities in accessing anti-malarial drug treatment in Eastern Indonesia, with a high proportion of untreated malaria cases across the areas. Findings from this study could be used as baseline information to improve access to anti-malarial drug treatment and better target malaria intervention in Eastern Indonesia.

Demographic, psychological, and experiential correlates of SARS-CoV-2 vaccination intentions in a sample of Canadian families

The COVID-19 pandemic has been ongoing for close to a year, with second waves occurring presently and many viewing vaccine uptake as the most likely way to curb successive waves and promote herd immunity. Reaching herd immunity status likely necessitates that children, as well as their parents, receive a vaccine targeting SARS-CoV-2. In this exploratory study, we investigated the demographic, experiential, and psychological factors associated with the anticipated likelihood and speed of having children receive a SARS-CoV-2 vaccine in a sample of 455 Canadian families (858 children; parents' mean age = 38.2 ± 6.82 years). Using linear mixed-effects and proportional odds logistic regression models, we demonstrated that older parental age, living in the Prairies (relative to Central Canada), more complete child vaccination history, and a greater tendency to prioritise the risks of the disease relative to the risks of side effects (i.e. lower omission bias) were associated with higher likelihoods of intention to vaccinate participants' children, with trend-level associations with lower perceived danger of the vaccine and higher psychological avoidance of the pandemic. Faster speed of intended vaccination was predicted by a similar constellation of variables with an additional predictor of a child in the family having a COVID-19 related health risk being associated with slower intended speed. Results are discussed concerning public health knowledge mobilisation and the unique Canadian health landscape.

Integrating health behavior theories to predict American's intention to receive a COVID-19 vaccine

OBJECTIVE

Integrating constructs from three prominent health behavior theories including the extended parallel process model, the health belief model, and the theory of planned behavior, this study seeks to identify sociopsychological factors that influenced American's intention to receive a COVID-19 vaccine.

METHOD

An online survey was delivered to a U.S. sample (N = 934), assessing the influences of risk perception and fear associated with COVID-19, beliefs about and attitudes toward COVID-19 vaccines, self-efficacy, social and psychological contexts, and demographic characteristics on people's intention to get COVID-19 vaccines.

RESULTS

Most respondents intended to get vaccinated. However, they tended to underestimate their risks of contracting COVID-19. Disease exposure led to higher uptake intent via the mediation of fear. Safety concerns negatively influenced vaccination intention, while perceived community benefits were positively associated with vaccination intention. Positive attitudes toward vaccines and recent vaccine history were positively linked to vaccination intent.

CONCLUSION

This study attests the effectiveness of HBT constructs in predicting people's intention to receive a COVID-19 vaccine.

PRACTICE IMPLICATIONS

The results point to the importance of fostering confidence in vaccine safety and countering overoptimism of individual susceptibility to the disease in interventions promoting COVID-19 vaccines uptake.

Nurses' and teachers' perceived barriers and facilitators to the uptake of the Human Papilloma Virus (HPV) vaccination program in Iquitos, Peru: A qualitative study

Globally, over 300,000 women die of cervical cancer annually. Given that human papillomavirus vaccines are highly effective in the primary prevention of cervical cancer, it is important to explore the barriers and facilitators to vaccination uptake in areas where the burden of disease remains high. This study, informed by the socio-ecological model, aimed to qualitatively explore vaccination uptake via in-depth interviews with eleven nurses and ten teachers involved in vaccine delivery in Iquitos, Peru. The results highlighted that vaccine uptake was influenced by multiple factors including individuals' knowledge and attitudes, community beliefs, geography, and policy level variables. Findings suggested that professionals were informed and supportive of the HPV vaccination program but perceived that parents were uninformed about the vaccine. There is a need for community education programs, for a revision of the process of obtaining parental consent, for improved communication between professionals and for involvement of grassroots staff in policy making.

Home testing for COVID-19 and other virus outbreaks: The complex system of translating to communities

Home testing is an emerging innovation that can enable nations and health care systems to safely and efficiently test large numbers of patients to manage COVID-19 and other viral outbreaks.  In this position paper, we explore the process of moving home testing across the translational continuum from labs to households, and ultimately into practice and communities for optimal public health impact. We focus on the four translational science drivers to accelerate the implementation of systems-wide home testing programmes 1) collaboration and team science, 2) technology, 3) multilevel interventions, and 4) knowledge integration. We use the Socio Ecological Model (SEM) as a framework to illustrate our vision for the ideal future state of a comprehensive system of stakeholders utilising tech-enabled home testing for COVID-19 and other virus outbreaks, and we suggest SEM as a tool to address key translational readiness and response questions.

Using Influenza Vaccination Location Data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) to Expand COVID-19 Vaccination Coverage

Effective COVID-19 vaccine distribution requires prioritizing locations that are accessible to high-risk target populations. However, little is known about the vaccination location preferences of individuals with underlying chronic conditions. Using data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS), we grouped 162,744 respondents into high-risk and low-risk groups for COVID-19 and analyzed the odds of previous influenza vaccination at doctor’s offices, health departments, community settings, stores, or hospitals. Individuals at high risk for severe COVID-19 were more likely to be vaccinated in doctor’s offices and stores and less likely to be vaccinated in community settings.

Perceived enablers and barriers of community engagement for vaccination in India: Using socioecological analysis

BACKGROUND

There is high level policy consensus in India that community engagement (CE) improves vaccination uptake and reduces burden of vaccine preventable diseases. However, to date, vaccination studies in the country have not explicitly focused on CE as an outcome in and of itself. Therefore, this study sought to examine the barriers and enablers of community engagement for vaccination in India.

METHODS

Employing qualitative methods, twenty-five semi-structured elite interviews among vaccine decisionmakers' were triangulated with twenty-four national-level vaccine policy documents and researcher field notes (December 2017 to February 2018). Data collected for this study included perceptions and examples of enablers of and barriers to CE for vaccination uptake. Concepts, such as the absence of formal procedures or data collection approaches related to CE, were confirmed during document review, and a final convening to review study results was conducted with study respondents in December 2018 and January 2019 to affirm the general set of findings from this study. The Social Ecological Model (SEM) was used to organize and interpret the study findings.

RESULTS

Although decisionmakers and policy documents generally supported CE, there were more CE barriers than facilitators in the context of vaccination, which were identified at all social-ecological levels. Interviews with vaccine decisionmakers in India revealed complex systemic and structural factors which affect CE for vaccination and are present across each of the SEM levels, from individual to policy. Policy-level enablers included decisionmakers' political will for CE and policy documents and interviews highlighted social mobilization, whereas barriers were lack of a CE strategy document and a broad understanding of CE by decisionmakers. At the community level, dissemination of Social-behavioral Change Communication (SBCC) materials from the national-level to the states was considered a CE facilitator, while class, and caste-based power relations in the community, lack of family-centric CE strategies, and paternalistic attitude of decisionmakers toward communities (the latter reported by some NGO heads) were considered CE barriers. At the organizational level, partnerships with local organizations were considered CE enablers, while lack of institutionalized support to formalize and incentivize these partnerships highlighted by several decisionmakers, were barriers. At the interpersonal level, SBCC training for healthcare workers, sensitive messaging to communities with low vaccine confidence, and social media messaging were considered CE facilitators. The lack of strategies to manage vaccine related rumors or replicate successful CE interventions during the during the introduction and rollout of new vaccines were perceived as CE barriers by several decisionmakers.

CONCLUSION

Data obtained for this study highlighted national-level perceptions of the complexities and challenges of CE across the entire SEM, from individual to systemic levels. Future studies should attempt to associate these enablers and barriers with actual CE outcomes, such as participation or community support in vaccine policy-making, CE implementation for specific vaccines and situations (such as disease outbreaks), or frequency of sub-population-based incidents of community resistance and community facilitation to vaccination uptake. There would likely be value in developing a population-based operational definition of CE, with a step-by-step manual on 'how to do CE.' The data from this study also indicate the importance of including CE indicators in national datasets and developing a compendium documenting CE best-practices. Doing so would allow more rigorous analysis of the evidence-base for CE for vaccination in India and other countries with similar immunization programs.

How can human-centered design build a story-based video intervention that addresses vaccine hesitancy and bolsters vaccine confidence in the Philippines? A mixedmethod protocol for project SALUBONG

INTRODUCTION

Since the onset of a dengue vaccine controversy in late 2017, vaccine confidence has plummeted in the Philippines, leading to measles and polio outbreaks in early 2019. This protocol outlines a human-centered design (HCD) approach to co-create and test an intervention that addresses vaccine hesitancy (VH) via narrative and empathy with and among families and healthcare workers. METHODS AND ANALYSIS: 'Salubong' is a Filipino term that means to welcome someone back into one's life, reinforcing notions of family ties and friendships. We apply this sentiment to vaccines. Following the phases of HCD, guided by a theoretical framework, and drawing from locally held understandings of faith and acceptance, we will conduct in-depth interviews (IDIs) and focus group discussions (FGDs) in rural and urban Filipino communities that witnessed dramatic increases in measles cases in recent years. During qualitative engagements with caretakers, providers, and policymakers, we will collect narratives about family and community perceptions of childhood vaccinations, public health systems and opportunities to restore faith. IDIs and FGDs will continuously inform the development of (and delivery mechanisms for) story-based interventions. Once developed, we will test our co-created interventions among 800 caretakers and administer a VH questionnaire prior to and immediately following the intervention encounter. We will use the feedback gained through the survey and Kano-style questionnaires to further refine the intervention. Considering the data collection challenges posed by the ongoing COVID-19 pandemic, we have developed workarounds to conduct data collection primarily online. We will use systematic online debriefings to facilitate comprehensive participation of the full research team.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Institutional Review Board of the Research Institute for Tropical Medicine (number 2019-44) and Ethical Commission of Heidelberg University, Faculty of Medicine (S-833/2019). Study findings will be disseminated in scientific conferences and published in peer-reviewed journals.

Community and health system factors associated with antiretroviral therapy initiation among men and women in Malawi: a mixed methods study exploring gender-specific barriers to care

BACKGROUND

Although community and health system factors are known to be critical to timely antiretroviral therapy (ART) initiation, little is known about how they affect men and women.

METHODS

We examined community- and health system-level factors associated with ART initiation in Malawi and whether associations differ by gender; 312 ART initiates and 108 non-initiates completed a survey; a subset of 30 individuals completed an indepth interview. Quantitative data were analyzed using univariate and multivariate logistic regressions, with separate models by gender. Qualitative data were analyzed through constant comparison methods.

RESULTS

Among women, no community-level characteristics were associated with ART initiation in multivariable models; among men, receiving social support for HIV services (adjusted OR [AOR]=4.61; p<0.05) was associated with ART initiation. Two health system factors were associated with ART initiation among men and one for women: trust that accessing ART services would not lead to unwanted disclosure (women: AOR=4.51, p<0.01; men: AOR=1.71, p<0.01) and trust that clients were not turned away from ART services (men: 12.36, p=0.001).

CONCLUSIONS

Qualitative data indicate that men were concerned about unwanted disclosure due to engaging in ART services and long waiting times for services. Interventions to remove health system barriers to ART services should be explored to promote social support among men.