The demographics of vaccine hesitancy in Shanghai, China

A Prediction Model for Identifying Seasonal Influenza Vaccination Uptake Among Children in Wuxi, China: Prospective Observational Study

BACKGROUND

Predicting vaccination behaviors accurately could provide insights for health care professionals to develop targeted interventions.

OBJECTIVE

The aim of this study was to develop predictive models for influenza vaccination behavior among children in China.

METHODS

We obtained data from a prospective observational study in Wuxi, eastern China. The predicted outcome was individual-level vaccine uptake and covariates included sociodemographics of the child and parent, parental vaccine hesitancy, perceptions of convenience to the clinic, satisfaction with clinic services, and willingness to vaccinate. Bayesian networks, logistic regression, least absolute shrinkage and selection operator (LASSO) regression, support vector machine (SVM), naive Bayes (NB), random forest (RF), and decision tree classifiers were used to construct prediction models. Various performance metrics, including area under the receiver operating characteristic curve (AUC), were used to evaluate the predictive performance of the different models. Receiver operating characteristic curves and calibration plots were used to assess model performance.

RESULTS

A total of 2383 participants were included in the study; 83.2% of these children (n=1982) were <5 years old and 6.6% (n=158) had previously received an influenza vaccine. More than half (1356/2383, 56.9%) the parents indicated a willingness to vaccinate their child against influenza. Among the 2383 children, 26.3% (n=627) received influenza vaccination during the 2020-2021 season. Within the training set, the RF model showed the best performance across all metrics. In the validation set, the logistic regression model and NB model had the highest AUC values; the SVM model had the highest precision; the NB model had the highest recall; and the logistic regression model had the highest accuracy, F1 score, and Cohen κ value. The LASSO and logistic regression models were well-calibrated.

CONCLUSIONS

The developed prediction model can be used to quantify the uptake of seasonal influenza vaccination for children in China. The stepwise logistic regression model may be better suited for prediction purposes.

Understanding the determinants of vaccine hesitancy in the United States: A comparison of social surveys and social media

The COVID-19 pandemic prompted governments worldwide to implement a range of containment measures, including mass gathering restrictions, social distancing, and school closures. Despite these efforts, vaccines continue to be the safest and most effective means of combating such viruses. Yet, vaccine hesitancy persists, posing a significant public health concern, particularly with the emergence of new COVID-19 variants. To effectively address this issue, timely data is crucial for understanding the various factors contributing to vaccine hesitancy. While previous research has largely relied on traditional surveys for this information, recent sources of data, such as social media, have gained attention. However, the potential of social media data as a reliable proxy for information on population hesitancy, especially when compared with survey data, remains underexplored. This paper aims to bridge this gap. Our approach uses social, demographic, and economic data to predict vaccine hesitancy levels in the ten most populous US metropolitan areas. We employ machine learning algorithms to compare a set of baseline models that contain only these variables with models that incorporate survey data and social media data separately. Our results show that XGBoost algorithm consistently outperforms Random Forest and Linear Regression, with marginal differences between Random Forest and XGBoost. This was especially the case with models that incorporate survey or social media data, thus highlighting the promise of the latter data as a complementary information source. Results also reveal variations in influential variables across the five hesitancy classes, such as age, ethnicity, occupation, and political inclination. Further, the application of models to different MSAs yields mixed results, emphasizing the uniqueness of communities and the need for complementary data approaches. In summary, this study underscores social media data's potential for understanding vaccine hesitancy, emphasizes the importance of tailoring interventions to specific communities, and suggests the value of combining different data sources.

Gap between cognitions and behaviors among children's guardians of influenza vaccination: The role of social influence and vaccine-related knowledge

The seasonal influenza vaccine coverage remains suboptimal among children even though guardians expressed high willingness to vaccinate their children. This study aimed to determine the association between vaccine hesitancy and uptake to facilitate vaccination; thus, bridging the gap. A cross-sectional design, using stratified cluster random sampling, was conducted among guardians of 0-59-month-old Chinese children from July to October in 2019. A structural equation model was applied to explore the interrelationships between factors including vaccine hesitancy, vaccination, social influence, and relative knowledge among guardians. Of the 1,404 guardians, 326 were highly hesitant to vaccinate their children, 33.13% (108/326) of whom had vaccinated their children. Moreover, 517 and 561 guardians had moderate and low vaccine hesitancy, with corresponding vaccine coverage of 42.75% (221/517) and 47.95% (269/516). Guardians' gender, age, and education level were demographic variables with significant moderating effects. Social influence considered impact of communities, family members, friends, neighbors, healthcare workers, bad vaccination experience and sense on price. Actual vaccine uptake was negatively significantly associated with hesitancy (β = -0.11, p < .001) with positive association with social influence (β = 0.61, p < .001). Vaccine hesitancy was negatively significantly associated with relative knowledge (β = -2.14, p < .001) and social influence (β = -1.09, p < .001). A gap is noted between cognitions and behaviors among children's guardians regarding influenza vaccination. A comprehensive strategy including emphasizing benefits of the influenza vaccination, risk of infection, and ensuring high vaccine confidence among healthcare workers can help transform the willingness to engage in the behavior of vaccination.

Worldwide Child Routine Vaccination Hesitancy Rate among Parents of Children Aged 0-6 Years: A Systematic Review and Meta-Analysis of Cross-Sectional Studies

Routine vaccine hesitancy is a major global health challenge observed in over 190 countries worldwide. This meta-analysis aims to determine the worldwide prevalence of routine vaccination hesitancy among parents of children aged 0-6. An extensive search was conducted in four scientific databases: PubMed, Scopus, Web of Science, and the Cochrane Library. Studies were included if they reported hesitancy related to WHO-recommended routine immunizations for children under 7 years of age. A single-arm meta-analysis was performed using the OpenMeta[Analyst] software. An initial search retrieved 5121 articles, of which only 23 publications, involving 29,131 parents, guardians, and caregivers from over 30 countries met the inclusion criteria and quality assessment. The cumulative prevalence of parental vaccine hesitancy was found to be 21.1% (95% CI = 17.5-24.7%, I2 = 98.86%, p < 0.001). When stratifying the prevalence of vaccine hesitancy per WHO region, significant variations were observed, ranging from 13.3% (95% CI = 6.7-19.9%, I2 = 97.72%, p < 0.001) in the Region of the Americas to 27.9% (95% CI = 24.3-31.4%) in the Eastern Mediterranean region. The study findings highlight the need for healthcare providers and governments to develop and improve comprehensive programs with communication strategies to reduce parental vaccine hesitancy.

Knowledge, Attitudes, Intentions and Vaccine Hesitancy among Postpartum Mothers in a Region from the Northwest of Romania

This study aims to identify the presence of vaccine hesitancy and the factors that could have determined it in a group of mothers in the postpartum period, with an evaluation of both the level of knowledge and information, as well as the attitudes, perceptions, intentions and sources of information about vaccination. The study was based on a survey-Vaccine Hesitancy Identification Survey-applied in two maternity wards from Bihor County and structured into six subscales (34 items). Based on the answers to the key questions ("Which of the following statements best describes your plans for vaccinating your child?"-item 1 of subscale 4; "Overall, how hesitant do you consider yourself to be about vaccinating your child?"-item 4 of subscale 4), we identified two groups: the group of mothers without hesitant behavior (non-hesitant), called the group pro vaccine (GPV), and the group of mothers with hesitant behavior, called the group non vaccine (GNV). Vaccine hesitancy was identified in our study in 47.28% of the participants (191 of the 404 mothers included). Most of them come from an urban environment (57.59%), have university and post-secondary education (58.64%) and are prim parous (58.64%). The behavior of participants from GNV is influenced by a low level of knowledge and information regarding vaccination and by concerns related to adverse reactions, new vaccines and the number of vaccines administered. Also, this group is characterized by an increased perception of the risks related to vaccination, while the perception of the risks associated with the disease is low. For all subscales, important differences were registered between the two groups in favor of GPV, a group characterized by positive attitudes and perceptions and a better level of knowledge compared to GNV. This study aims to represent a starting point for the organization and running of information campaigns regarding vaccination at the level of Bihor County, especially in areas with low vaccination coverage, where this behavior is identified.

Decision-making in childhood vaccination: vaccine hesitancy among caregivers of under-5 children from a tertiary care institution in Eastern India

Background

Acceptance of vaccines has been on a decline in recent times, with vaccine hesitancy being listed as one of the top 10 global health threats. This study analysed vaccine hesitancy and belief towards vaccination among caregivers of children aged below 5 years.

Methods

In this cross-sectional study, 196 caregivers of children aged 6 months to below 5 years who had attended an immunization clinic at a tertiary care institute of Eastern India from March to May 2019 were surveyed. Consecutive sampling was used to recruit eligible study participants. The survey assessed the attitudes of parents towards childhood vaccination by using the Vaccine Hesitancy Scale and their beliefs towards vaccination. Univariate analysis was performed to assess the association of various sociodemographic factors with vaccine hesitancy.

Results

Among the caregivers, most (48%) mothers were aged 26-35 years, literate and homemakers. Vaccine hesitancy was observed in 9.18% of the participants. Only the age of the child was significantly associated with vaccine hesitancy. Nearly half (48.5%) of the participants were concerned about the serious adverse effects of vaccines, and a third (30.6%) agreed that newer vaccines are associated with higher risks than the older ones. Caregivers felt that vaccines are no longer required for uncommon diseases.

Conclusion

Concerns regarding vaccine hesitancy are prevalent even among caregivers attending a tertiary care institute. Thus, additional studies are required to assess hesitancy in urban, rural, remote and inaccessible areas. Policymakers ought to conduct periodic assessments and implement necessary remedial measures for the long-term sustenance of the benefits of the national immunization programme.

Assessing vaccine hesitancy using the WHO scale for caregivers of children under 3 years old in China

Introduction

Vaccine hesitancy may increase infectious disease burden and impede disease control efforts, while few studies have measured such a phenomenon with a standardized tool in China. This study aimed to test the validation of the Vaccine Hesitancy Scale (VHS) developed by the WHO SAGE Working Group among caregivers and examine demographic characteristics associated with caregiver hesitancy in six provinces of China.

Methods

Using a multistage sampling design, this study was conducted in 36 immunization clinics in six provinces from December 2019 to August 2020. Caregivers of children aged 0-3  years were included. The VHS was used to assess vaccine hesitancy. The construct validity and internal consistency of the scale were assessed. Associations between caregivers' characteristics and vaccine hesitancy were examined by simple and multiple linear regression models.

Results

Of the 3,359 participants included, a two-factor structure within the scale was identified, consisting of "lack of confidence" (1.89 ± 0.53) and "risks" (3.20 ± 0.75). Caregivers engaged in medical work expressed more confidence and were less concerned about risks compared to those of non-medical staff (p < 0.05). Participants with higher income levels were more confident (p < 0.05), while those surveyed after the COVID-19 pandemic, who were mothers, who had an older child, or who were raising a second or above birth child, had less concern about risks (p < 0.05).

Discussion

We found that the VHS had acceptable reliability and construct validity and caregivers' hesitancy was driven more by concerns about risks than by the lack of confidence. Countering these concerns will be particularly important among non-medical staff, lower income, child's fathers, having a younger child, or raising first-birth child groups.

Parental Seasonal Influenza Vaccine Hesitancy and Associated Factors in Shanghai, China, during the COVID-19 Pandemic: A Cross-Sectional Study

BACKGROUND

Seasonal influenza may overlap with the COVID-19 pandemic, and children are one of the priority populations for influenza vaccination in China, yet vaccine coverage has been low. This study aimed to investigate the extent of parental influenza vaccine hesitancy (IVH) and to explore the associated factors.

METHODS

The study was conducted in Shanghai, China, from 1 June 2022 to 31 July 2022, using an anonymous questionnaire to survey a random sample of parents of children aged six months to 14 years. Binary logistic regression models were used to identify factors associated with IVH.

RESULTS

Of the 5016 parents, 34.05% had IVH. Multivariate analysis showed that after adjustment for non-modifiable markers (i.e., sociodemographic, health status, and past vaccination status), being affected by negative influenza vaccine news and having higher "complacency" were positively associated with parental IVH. Higher knowledge of influenza vaccination, being recommended by healthcare workers (HCWs), people around having a positive attitude toward influenza vaccine and having higher levels of "confidence" and "convenience" were negatively associated with parental IVH.

CONCLUSIONS

In China, public health education aimed at modifying vaccination-related attitudes and beliefs, as well as knowledge and societal influences, could help reduce influenza vaccination hesitancy.

A systematic literature review to clarify the concept of vaccine hesitancy

Vaccine hesitancy (VH) is considered a top-10 global health threat. The concept of VH has been described and applied inconsistently. This systematic review aims to clarify VH by analysing how it is operationalized. We searched PubMed, Embase and PsycINFO databases on 14 January 2022. We selected 422 studies containing operationalizations of VH for inclusion. One limitation is that studies of lower quality were not excluded. Our qualitative analysis reveals that VH is conceptualized as involving (1) cognitions or affect, (2) behaviour and (3) decision making. A wide variety of methods have been used to measure VH. Our findings indicate the varied and confusing use of the term VH, leading to an impracticable concept. We propose that VH should be defined as a state of indecisiveness regarding a vaccination decision.

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.

Describing the Myths and Misconceptions Regarding COVID-19 Vaccines Among the Population of the Kingdom of Saudi Arabia

Objectives

This study aims to describe the common myths and misconceptions in addition to the perception and attitudes toward coronavirus disease 2019 (COVID-19) vaccines in the Saudi Arabian community.

Methods

This is a cross-sectional study that included adults (18 years and older) residing in the Kingdom of Saudi Arabia. Participants were asked to complete an online survey that evaluated their perception and attitudes toward the available COVID-19 vaccines in Saudi Arabia. Statistical comparison between two groups and more was done using chi-square, independent t-test, and one-way ANOVA.

Results

A total of 471 responses were analyzed with a majority (83.2%) believing that vaccinations are important. The vaccine preferred among the Saudi Arabian population was Pfizer (65.4%). More than half of our respondents (54.8%) strongly agreed that COVID-19 vaccines can reduce the severity of the COVID-19 infection. Respondents in the healthcare sector were significantly more likely to have a more positive view on vaccines compared to those in non-healthcare sectors (p < 0.001).

Conclusion

The Saudi Arabian population has shown substantial awareness about COVID-19 vaccines; however, public health officials need to further increase awareness measures on COVID-19 vaccines to limit myths and misconceptions, especially among certain populations that are more prone to it.

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.

Changes in the public attitude toward childhood vaccine and the COVID-19 vaccine during different periods: A repeated cross-section study in Wuxi city, China

BACKGROUND

It was reported that one in four parents were hesitant about vaccinating their children in China. Previous studies have revealed a declining trend in the vaccine willingness rate in China. There is a need to monitor the level of parental vaccine hesitancy towards routine childhood vaccination and hesitancy toward the coronavirus disease 2019 (COVID-19) vaccine during the ongoing COVID-19 pandemic.

OBJECTIVE

This study aimed to assess changes in trends of parental attitudes toward routine childhood vaccine and COVID-19 vaccinations across different time periods in China.

METHODS

Three waves of cross-sectional surveys were conducted on parents residing in Wuxi City in Jiangsu province, China from September to October 2020, February to March 2021, and May to June 2021. Participants were recruited from immunization clinics. Chi-square tests used to compare the results of the three surveys, controlling for sociodemographic factors. Binary and multivariable logistic regression analysis was used to examine factors related to parental vaccine hesitancy and COVID-19 vaccine willingness.

RESULTS

Overall, 2,881, 1,038, and 1,183 participants were included in the survey's three-waves. Using the Vaccine Hesitancy Scale, 7.8%, 15.1%, and 5.5% of parents showed hesitancy to children vaccination (P<.001), and 59.3%, 64.6%, and 92.0% of parents agreed to receive a COVID-19 vaccine themselves in the first, second, and third surveys, respectively (P<.001). In all three surveys, "concerns about vaccine safety and side effects" was the most common reason for refusal.

CONCLUSIONS

There has been an increasing acceptance of COVID-19 vaccination in Wuxi City, China. Effective interventions need be taken to mitigate public concerns about vaccine safety.

CLINICALTRIAL

Vaccination conspiracy beliefs among social science & humanities and STEM educated people-An analysis of the mediation paths

Understanding vaccine hesitancy is becoming increasingly important, especially after the global outbreak of COVID-19. The main goal of this study was to explore the differences in vaccination conspiracy beliefs between people with a university degree coming from different scientific fields—Social Sciences & Humanities (SH) and Science, Technology, Engineering and Mathematics (STEM). The study was conducted on an online convenience sample of respondents with college and university degrees in Croatia (N = 577). The results revealed that respondents educated in SH proved to be more prone to vaccination conspiracy beliefs. The indirect effect through science literacy was confirmed, while this was not the case for the indirect effects through health beliefs (natural immunity beliefs) and trust in the healthcare system. However, all three variables were important direct predictors of vaccination conspiracy beliefs. Female gender and religiosity were positively correlated with vaccination conspiracy beliefs, while age was not a statistically significant predictor. The authors concluded by emphasizing the necessity of the more theoretically elaborated approaches to the study of the educational and other socio-demographic differences in vaccine hesitancy.

Acceptability of and barriers to human papillomavirus vaccination in China: A systematic review of the Chinese and English scientific literature

INTRODUCTION

Widespread adoption of the human papillomavirus (HPV) vaccine will require population acceptance and tailoring of immunisation services to community needs and preferences. We examined peer-reviewed publications on the acceptability of and barriers to the HPV vaccine across China.

METHODS

We searched English (MEDLINE, Embase, and Web of Science) and Chinese (CNKI, VIP, Wanfang data) databases between 1 January 2006 and 31 December 2017. We adopted a narrative approach for data synthesis.

RESULTS

We identified 73 studies. The overall median acceptability of HPV vaccine was 71.8% (Q1-Q3: 58.6%-81%). Low levels of acceptability (<40%) of HPV vaccine were found in eastern regions of China. The largest differences of acceptability were observed between rural western regions (all >90%) and urban eastern regions (all <35%). Despite these regional variations, common barriers to HPV vaccine acceptance were concerns about vaccine safety, uncertainty over vaccine effectiveness, low perceived risk of cervical cancer and the price of the vaccine. The level of willingness to pay for the HPV vaccine (over 153 US dollars) was very low (<7%).

CONCLUSION

The acceptability of and attitudes towards HPV vaccine vary by regions and populations across China. HPV vaccination programmes will need to tailor service delivery as well as information materials to take account of regional concerns.

Validation of the World Health Organization's parental vaccine hesitancy scale in China using child vaccination data

Evidence for the validity and reliability of the World Health Organization's 10-item vaccine hesitancy scale (VHS) in different settings is not sufficient, especially for criteria validity. This study aimed to assess the validity and reliability of the VHS using child vaccination data in China. A cross-sectional survey was performed with parents of 19-48-month-old children at six vaccination clinics in Wuxi City between September and October 2020. The VHS was revised to category A (expanded program on immunization, EPI) VHS and category B (Non-EPI) VHS. Factor analysis was used to confirm the latent domain and to assess the model structure. The average variance extracted (AVE) was calculated to assess convergent validity, and Cronbach's α and composite reliability (CR) were used to determine internal consistency. The association between VHS scores and children's vaccination status was examined to assess criteria validity using logistic regression. The survey response rate was 75.3% (n = 802). Two factors were identified, explaining 64.60% and 63.34% of the common variance in categories A and B VHS, respectively. The Cronbach's α of > 0.7 and CR of >0.7 in the scale indicated the VHS has acceptable internal consistency. The AVE values indicated that convergent validity was not ideal for the VHS. There were no statistically significant associations between VHS scores and vaccination status, indicating that the criterion validity was not ideal. The VHS needs improvement before becoming a standard survey tool.

Correlates of Covid-19 Vaccine Acceptance among Residents of Ohio: A Cross-sectional Study

BACKGROUND

Recent studies in the United States have shown that between 56 to 74% are willing to receive the COVID-19 vaccine. A significant portion of the population should be vaccinated to avoid severe illness and prevent unnecessary deaths. We examined correlates of COVID-19 vaccine acceptance among a representative sample of adults residing in Ohio.

METHODS

We conducted a cross-sectional study using an online platform (n = 2358). Descriptive statistics, chi-square test and multivariable regression analysis were performed.

RESULTS

Overall, 59.1% of the participants indicated COVID-19 vaccine acceptance to be vaccinated. In the multivariable model, the likelihood of COVID-19 vaccine acceptance was lower for younger individuals compared to those 55 years and older. The odds of COVID-19 vaccine acceptance were lower for: females compared to males (OR 0.58, 95% CI: 0.47-0.71; P = 0.001), non-Hispanic blacks compared to non-Hispanic whites (OR: 0.49 95% CI: 0.35-0.70; P = 0.001), previously married (OR 0.64 95% CI: 0.49-0.84; P = 0.002) and never been married (OR 0.75 95% CI: 0.59-0.96; P = 0.023) compared to married people, individuals with less than high school (OR 0.21 95% CI: 0.08-0.60; P = 0.003) and high school education (OR: 0.45 95% CI: 0.36-0.55; P < 0.001) compared to those with education beyond high school, and for individuals who had no confidence in the abilities of the state government (OR 0.69 95% CI: 0.53-0.89; P = 0.005) and other world governments to combat COVID-19 (OR 0.67 95% CI: 0.50-0.91; P = 0.009). A one unit increase in knowledge about COVID-19 (OR 1.19, 95% CI: 1.13-1.26; P < 0.001), behavioral adherence (OR 1.25, 95% CI: 1.15-1.37; P < 0.001), perceived susceptibility (OR 1.10, 95% CI: 1.03-1.17; P = 0.004), perceived severity (OR 1.09, 95% CI: 1.03-1.16; P = 0.003), and trust in COVID-19 messages from the government scores (OR 1.08, 95% CI: 1.06-1.10; P < 0.001) were associated with an increase in the likelihood of COVID-19 vaccine acceptance.

CONCLUSIONS

COVID-19 vaccine acceptance differed by sociodemographic and other modifiable factors. Findings can inform local public health authorities in the development of effective, context-specific communication strategies to improve vaccination uptake.

Using an extended protection motivation theory to explain vaccine hesitancy: a cross-sectional study among Chinese adults

Background

Vaccine hesitancy was listed as one of the top 10 issues threatening global health in 2019. The objectives of this study were to (a) use an extended protection motivation theory (PMT) with an added trust component to identify predictors of vaccine hesitancy and (b) explore the predictive ability of vaccine hesitancy on vaccination behavior.

Methods

We conducted an online questionnaire from February 9 to April 9, 2021, in China. The target population was Chinese residents aged 18 and over. A total of 14,236 responses were received. Structural equation modeling was used to test the extended PMT model hypotheses.

Results

A total of 10,379 participants were finally included in this study, of whom 52.0% showed hesitancy toward vaccination. 2854 (27.5%) participants reported that they got flu shots in the past year, and 2561 (24.7%) participants were vaccinated against COVID-19. 2857 (27.5%) participants engaged in healthcare occupation. The model explained 85.7% variance of vaccine hesitancy. Self-efficacy was the strongest predictor, negatively associated with vaccine hesitancy (β = −0.584; p < .001). Response efficacy had a negative effect on vaccine hesitancy (β = −0.372; p < .001), while threat appraisal showed a positive effect (β = 0.104; p < .001). Compared with non-health workers, health workers showed more vaccine hesitancy, and response efficacy was the strongest predictor (β = −0.560; p < .001). Vaccine hesitancy had a negative effect on vaccination behavior (β = −0.483; p < .001), and the model explained 23.4% variance of vaccination behavior.

Conclusions

This study demonstrates that the extended PMT model is efficient in explaining vaccine hesitancy. However, the predictive ability of vaccine hesitancy on vaccination behavior is limited.

Willingness, beliefs, and barriers regarding the COVID-19 vaccine in Saudi Arabia: a multiregional cross-sectional study

Background

The coronavirus disease 2019 (COVID-19) has spread worldwide, and the vaccine remains the ultimate cornerstone to overcoming its long-term impact. Vaccine hesitancy might obstruct the effort to achieve herd immunity and eradicate the virus. We assessed Saudi Arabian individuals’ willingness, beliefs, and barriers regarding the COVID-19 vaccine and their adherence to preventive measures during and after the pandemic.

Methods

A self-administered electronic validated questionnaire was distributed among the five major regions in Saudi Arabia between November and December 2020. The questionnaire addressed the sociodemographic data, beliefs, potential barriers, parents’ acceptance of COVID-19 vaccination for their children, and adherence to protective measures during and after the pandemic.

Results

Of 8,056 participants, 4,218 (52.4%) of a non-representative sample were willing to be vaccinated against COVID-19. Being a young adult, male, having less than a high school degree, being a smoker, having a chronic disease, and having a history of seasonal influenza vaccine uptake were positive predictors of COVID-19 vaccine acceptance. Hesitant participants reported concerns about vaccine side effects and safety as the main barriers to accepting the COVID-19 vaccine. Some refusers (26.1%) declared that they would reconsider vaccination only if the safety and effectiveness of the vaccine were reported by more studies.

Conclusions

Our study revealed a promising willingness to accept the vaccine among the population, with positive beliefs and attitudes toward COVID-19 vaccination. However, a considerable proportion of the population was reluctant to accept the vaccine. Thus, publicly providing information about vaccine safety and implementing health education programs is crucial for increasing the public’s confidence in the vaccine.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01606-6.

Adaptation and validation of the Turkish version of the vaccine hesitancy 5 point Likert Scale

The decrease in vaccine acceptance has been recognized as an emerging public health problem and there is therefore a need for reliable and validated tools that identify vaccine hesitancy. The objective of this study was to adapt and validate the Turkish version of the Vaccine Hesitancy 5-point Likert Scale which was originally developed by the WHO Strategic Advisory Group of Experts on Immunization. The study was carried out in a Family Health Center (FHC) in Istanbul over the period June 1-November 30, 2020. The participants were parents who had applied to the FHC for well-child visits and had a child ≤18 months of age. After the process of translation and back-translation, the Turkish version was pilot-tested, and its test-retest reliability was evaluated among 40 parents at a two-week interval. The validation was carried out with 306 parents through exploratory factor analysis. There was no statistical difference between the test-retest scores (p = .17). The intraclass correlation coefficient was 0.98 (p < .001). Cronbach's alpha coefficient was 0.81. Factor analysis yielded two subscales that were named "confidence' and 'risk perception" and explained 63% of total variance. Our results suggest that the Turkish version of the Vaccine Hesitancy 5-point Likert Scale is a reliable and valid instrument.

Delays in routine childhood vaccinations and their relationship with parental vaccine hesitancy: a cross-sectional study in Wuxi, China

OBJECTIVES

This study aimed to examine childhood vaccination delay, explore the association between vaccination delay and parental vaccine hesitancy, and assess childhood vaccination delays during the coronavirus disease (COVID)-19 pandemic in China.

METHODS

This cross-sectional survey was conducted in Wuxi City. Participants were recruited from local vaccination clinics. Questionnaires were used to collect information about socio-demographics, vaccine hesitancy, and immunization clinic evaluations. Vaccination records were obtained from the Jiangsu Information Management System of Vaccination Cases.

RESULTS

Overall, 2728 participants were included. The coverage for seven category A vaccines (Expanded Program on Immunization (EPI)) was more than 95% at 24 months. The proportion of children vaccinated in a timely manner was the highest for the first dose of the hepatitis B vaccine (91.6%) and the lowest for the Bacillus-Calmette-Guerin vaccine (44.6%). More than 50% of the planned vaccinations were delayed in February and March 2020. The Vaccine Hesitancy Scale scores were not associated with vaccination delay (P = 0.842). Children's vaccination delays were negatively associated with parents who reported convenient access to clinics and satisfaction with immunization services (P = 0.020, P = 0.045).

CONCLUSIONS

EPI is highly successful in China. Despite vaccination delays due to the COVID-19 pandemic, coverage was recovered after lockdown restrictions were eased.

Knowledge, beliefs, attitudes and perceived risk about COVID-19 vaccine and determinants of COVID-19 vaccine acceptance in Bangladesh

Bangladesh govt. launched a nationwide vaccination drive against SARS-CoV-2 infection from early February 2021. The objectives of this study were to evaluate the acceptance of the COVID-19 vaccines and examine the factors associated with the acceptance in Bangladesh. In between January 30 to February 6, 2021, we conducted a web-based anonymous cross-sectional survey among the Bangladeshi general population. At the start of the survey, there was a detailed consent section that explained the study’s intent, the types of questions we would ask, the anonymity of the study, and the study’s voluntary nature. The survey only continued when a respondent consented, and the answers were provided by the respondents themselves. The multivariate logistic regression was used to identify the factors that influence the acceptance of the COVID-19 vaccination. A total of 605 eligible respondents took part in this survey (population size 1630046161 and required sample size 591) with an age range of 18 to 100. A large proportion of the respondents are aged less than 50 (82%) and male (62.15%). The majority of the respondents live in urban areas (60.83%). A total of 61.16% (370/605) of the respondents were willing to accept/take the COVID-19 vaccine. Among the accepted group, only 35.14% showed the willingness to take the COVID-19 vaccine immediately, while 64.86% would delay the vaccination until they are confirmed about the vaccine’s efficacy and safety or COVID-19 becomes deadlier in Bangladesh. The regression results showed age, gender, location (urban/rural), level of education, income, perceived risk of being infected with COVID-19 in the future, perceived severity of infection, having previous vaccination experience after age 18, having higher knowledge about COVID-19 and vaccination were significantly associated with the acceptance of COVID-19 vaccines. The research reported a high prevalence of COVID-19 vaccine refusal and hesitancy in Bangladesh. To diminish the vaccine hesitancy and increase the uptake, the policymakers need to design a well-researched immunization strategy to remove the vaccination barriers. To improve vaccine acceptance among people, false rumors and misconceptions about the COVID-19 vaccines must be dispelled (especially on the internet) and people must be exposed to the actual scientific facts.

Vaccine hesitancy towards childhood immunizations as a predictor of mothers' intention to vaccinate their children against COVID-19 in Saudi Arabia

Background

Despite the success of childhood immunization in reducing vaccine-preventable diseases, vaccine hesitancy is now a global health threat to this achievement. The current COVID-19 pandemic may change the picture of vaccine hesitancy toward childhood immunizations, which could influence the mothers’ intention to vaccinate their children against COVID-19.

Aim

To measure the prevalence and related factors of vaccine hesitancy towards childhood immunization during the era of COVID-19 along with the prevalence of mothers’ intention to vaccinate their children the future COVID-19 and its association with childhood vaccine hesitancy.

Methods

Cross sectional study was conducted among 270 Saudi mothers attending outpatient clinics at King Abdullah University Hospital (KAAUH) in Riyadh by purposive sampling technique. Data were collected from January to February 2021 using SAGE Group standardized questionnaire.

Results

Although most mothers strongly agree on the importance of the vaccine (79%), almost one-fourth of mothers were hesitant towards childhood immunization (24.31%). Similar percentage of mothers’ intended to vaccinate their children against COVID-19 in the next 6 months was reported (24%). Vaccine hesitancy was found to be a significant predictor of mothers’ intention. Mothers’ education level was significantly associated with being hesitant towards childhood immunization as well as the intention to accept the future COVID-19 vaccine (p < 0.05). Main reason that was highly significantly associated with being hesitant is the concerns about the side effect (50%).

Conclusion

The present study reported a considerable percentage of mothers who are hesitant towards childhood immunization which predicts their intension to vaccinate towards COVID19 and is associated with the level of education.

A critical review of measures of childhood vaccine confidence

The World Health Organization and global partners sought to identify existing measures of confidence in childhood vaccines, as part of a broader effort to measure the range of behavioural and social drivers of vaccination. We identified 14 confidence measures applicable to childhood vaccination in general, all published between 2010 and 2019. The measures examined 1-5 constructs and included a mean of 12 items. Validation studies commonly examined factor structure, internal consistency reliability, and criterion-related validity. Fewer studies examined convergent and discriminant validity, test-retest reliability, or used cognitive interviewing. Most measures were developed and validated only in high-income countries. These findings highlight the need for a childhood vaccine confidence measure validated for use in diverse global contexts.

An online survey of the attitude and willingness of Chinese adults to receive COVID-19 vaccination

Background: A safe and effective vaccine against COVID-19 has become a public health priority. However, little is known about the public willingness to accept a future COVID-19 vaccine in China. This study aimed to understand the willingness and determinants for the acceptance of a COVID-19 vaccine among Chinese adults.Methods: A cross-sectional survey using an online questionnaire was conducted in an adult population in China. Chi-square tests were used to identify differences for various intentions regarding COVID-19 vaccination. The t test was used to identify differences among vaccine hesitancy scores. Multivariable logistic regression was used to analyze the predicated factors associated with the willingness to receive a COVID-19 vaccine.Results: Of the 3195 eligible participants, 83.8% were willing to receive a COVID-19 vaccine, and 76.6% believed the vaccine would be beneficial to their health; however, 74.9% expressed concerns or a neutral attitude regarding its potential adverse effects. Of the participants, 76.5% preferred domestically manufactured vaccines and were more willing to be vaccinated than those who preferred imported vaccines. Multivariable logistic regression indicated that lack of confidence, complacency in regard to health, risk of the vaccine, and attention frequency were the main factors affecting the intention to receive a COVID-19 vaccine.Conclusion: Our study indicated that the respondents in China had a high willingness to accept a COVID-19 vaccine, but some participants also worried about its adverse effects. Information regarding the efficacy and safety of an upcoming COVID-19 vaccine should be disseminated to ensure its acceptance and coverage.

Vaccine Hesitancy: COVID-19 and Influenza Vaccine Willingness among Parents in Wuxi, China-A Cross-Sectional Study

Objectives: We aimed to (1) assess parental hesitancy about category A (Expanded Program on Immunization (EPI)) and B (non-EPI) vaccines, (2) assess parental willingness for COVID-19 and influenza vaccinations, and (3) explore the association of vaccination hesitancy of parents and healthcare workers (HCWs). Methods: The study was performed in Wuxi, eastern China between 21 September 2020 and 17 October 2020. Parents of children aged <18 years and HCWs were recruited from the selected immunization clinics. Vaccine hesitancy was assessed using the Strategic Advisory Group of Experts (SAGE) vaccine hesitancy survey (VHS) by summing the total score for 10 items (maximum 50 points). Results: A total of 3009 parents and 86 HCWs were included in the analysis. The category A VHS scores were significantly higher than the category B VHS scores (p = 0.000). Overall, 59.3% and 52.4% of parents reported willingness to avail COVID-19 and influenza vaccination for their children, respectively; 51.2% of the HCWs wanted to be vaccinated against COVID-19. Parental category B VHS scores were associated with HCW category B VHS scores (r = 0.928, p = 0.008). Conclusions: In China, parents are more hesitant about category B vaccines than category A vaccines. More than 40% of parents showed hesitancy and a refusal to use COVID-19 and influenza vaccines.

Vaccine Hesitancy: Characteristics of the Refusal of Childhood Vaccination in a Peruvian Population

Understanding the determinants of vaccine hesitancy is paramount to reinstate confidence in immunizations. The objective of this investigation was to explore the characteristics of the vaccination decision-making process that may result in the refusal of childhood immunization in Peru, during February-June 2020. A descriptive, cross-sectional study involving telephone interviews was executed in Peru. The Parents Attitudes about Childhood Vaccines (PACV) survey was used. A demographic analysis was done, followed by an unadjusted exploratory subgroup analysis. Out of 552 subjects, 9.8% were considered vaccine hesitant, 70.3% had purposively delayed vaccination, 88.4% thought fewer vaccines were better and 52.2% were concerned about vaccine safety. The level of hesitancy was inversely proportional to the level of education and the number of children at home. Mothers and subjects aged ≤29 years showed a greater level of vaccine hesitancy. This population displays a vaccine-hesitant conduct. Vaccine safety and the number of vaccines to administer are important determining factors. This behavior could be influenced by variables such as level of education, number of children at home, parental relationship, and age. These results help understand local vaccination behaviors. More studies are encouraged to confirm and validate these findings.

Demographics of Vaccine Hesitancy in Chandigarh, India

The impact of vaccine hesitancy on childhood immunization in low- and middle-income countries remains largely uncharacterized. This study describes the sociodemographic patterns of vaccine hesitancy in Chandigarh, India. Mothers of children <5 years old were sampled from a two-stage cluster, systematic sample based on Anganwadi child care centers in Chandigarh. Vaccine hesitancy was measured using a 10-item Vaccine Hesitancy Scale, which was dichotomized. A multivariable logistic regression assessed the association between socioeconomic factors and vaccine hesitancy score. Among 305 mothers, >97% of mothers thought childhood vaccines were important, effective, and were a good way to protect against disease. However, many preferred their child to receive fewer co-administered vaccines (69%), and were concerned about side effects (39%). Compared to the “other caste” group, scheduled castes or scheduled tribes had 3.48 times greater odds of vaccine hesitancy (95% CI: 1.52, 7.99). Those with a high school education had 0.10 times the odds of vaccine hesitancy compared to those with less education (95% CI: 0.02, 0.61). Finally, those having more antenatal care visits were less vaccine hesitant (≥4 vs. <4 visits OR: 0.028, 95% CI: 0.1, 0.76). As India adds more vaccines to its Universal Immunization Program, consideration should be given to addressing maternal concerns about vaccination, in particular about adverse events and co-administration of multiple vaccines.

Vaccine Hesitancy and Concerns About Vaccine Safety and Effectiveness in Shanghai, China

INTRODUCTION

Rapidly urbanizing communities in middle-income countries could be sources of vaccine hesitancy, and may create hot spots of low vaccination coverage. This study characterizes vaccine hesitancy in Shanghai and identifies disparities in vaccine safety and efficacy concerns by residency status-a marker for recent migration into the city.

METHODS

Parents of children aged ≤18 years from immunization clinics in Shanghai were enrolled in summer 2019, with the data analyzed during winter 2019-2020. The paper questionnaire used the Parental Attitudes towards Childhood Vaccines scale, which included questions about vaccine safety and efficacy concerns. The primary independent variable was residency-whether an individual was a Shanghai local or a recent migrant (i.e., non-local). Linear regression models assessed the relationship between residency and vaccine safety and efficacy concerns.

RESULTS

Among 1,021 participants, 65.4% had local residency, and the remainder were urban non-locals (13.1%) or rural non-locals (21.5%). A majority of parents expressed concerns about vaccine side effects (73.8%), vaccine safety (63.9%), and vaccine effectiveness (52.4%). Compared with locals, rural non-locals were more concerned about vaccine side effects (β=0.26, 95% CI=0.07, 0.46), vaccine safety (β=0.42, 95% CI=0.19, 0.65), and vaccine effectiveness (β=0.37, 95% CI=0.16, 0.58).

CONCLUSIONS

Differences in vaccine hesitancy by residency could lead to geographical and sociodemographic disparities in vaccination coverage and outbreaks of vaccine-preventable disease.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Hesitant or Not? The Association of Age, Gender, and Education with Potential Acceptance of a COVID-19 Vaccine: A Country-level Analysis

In December 2020, the first COVID-19 vaccines were approved. Despite more than 85 million reported cases and 1.8 million known deaths, millions worldwide say they may not accept it. This study assesses the associations of age, gender, and level of education with vaccine acceptance, from a random sample of 13,426 participants selected from 19 high-COVID-19 burden countries in June 2020. Based on univariable and multivariable logistic regression, several noteworthy trends emerged: women in France, Germany, Russia, and Sweden were significantly more likely to accept a vaccine than men in these countries. Older (≥50) people in Canada, Poland, France, Germany, Sweden, and the UK were significantly more favorably disposed to vaccination than younger respondents, but the reverse trend held in China. Highly educated individuals in Ecuador, France, Germany, India, and the US reported that they will accept a vaccine, but higher education levels were associated with lower vaccination acceptance in Canada, Spain, and the UK. Heterogeneity by demographic factors in the respondents' willingness to accept a vaccine if recommended by employers were substantial when comparing responses from Brazil, Ecuador, France, India, Italy, Mexico, Poland, Russia, South Africa, South Korea, Sweden, and the US. This information should help public health authorities target vaccine promotion messages more effectively.

Mapping global trends in vaccine confidence and investigating barriers to vaccine uptake: a large-scale retrospective temporal modelling study

BACKGROUND

There is growing evidence of vaccine delays or refusals due to a lack of trust in the importance, safety, or effectiveness of vaccines, alongside persisting access issues. Although immunisation coverage is reported administratively across the world, no similarly robust monitoring system exists for vaccine confidence. In this study, vaccine confidence was mapped across 149 countries between 2015 and 2019.

METHODS

In this large-scale retrospective data-driven analysis, we examined global trends in vaccine confidence using data from 290 surveys done between September, 2015, and December, 2019, across 149 countries, and including 284 381 individuals. We used a Bayesian multinomial logit Gaussian process model to produce estimates of public perceptions towards the safety, importance, and effectiveness of vaccines. Associations between vaccine uptake and a large range of putative drivers of uptake, including vaccine confidence, socioeconomic status, and sources of trust, were determined using univariate Bayesian logistic regressions. Gibbs sampling was used for Bayesian model inference, with 95% Bayesian highest posterior density intervals used to capture uncertainty.

FINDINGS

Between November, 2015, and December, 2019, we estimate that confidence in the importance, safety, and effectiveness of vaccines fell in Afghanistan, Indonesia, Pakistan, the Philippines, and South Korea. We found significant increases in respondents strongly disagreeing that vaccines are safe between 2015 and 2019 in six countries: Afghanistan, Azerbaijan, Indonesia, Nigeria, Pakistan, and Serbia. We find signs that confidence has improved between 2018 and 2019 in some EU member states, including Finland, France, Ireland, and Italy, with recent losses detected in Poland. Confidence in the importance of vaccines (rather than in their safety or effectiveness) had the strongest univariate association with vaccine uptake compared with other determinants considered. When a link was found between individuals' religious beliefs and uptake, findings indicated that minority religious groups tended to have lower probabilities of uptake.

INTERPRETATION

To our knowledge, this is the largest study of global vaccine confidence to date, allowing for cross-country comparisons and changes over time. Our findings highlight the importance of regular monitoring to detect emerging trends to prompt interventions to build and sustain vaccine confidence.

FUNDING

European Commission, Wellcome, and Engineering and Physical Sciences Research Council.

Addressing Vaccine Hesitancy in China: A Scoping Review of Chinese Scholarship

Despite the well-developed Chinese National Immunization Program, vaccine hesitancy in China is rising. As part of the response, Chinese scholars have studied determinants and proposed solutions to vaccination hesitancy. We performed a scoping review of Chinese literature (2007-2019), drawn from four Chinese databases. We mapped relevant information and presented a systemic account of the proposed determinants and responses to vaccine hesitancy in China. We identified 77 relevant studies that reveal four approaches to vaccine hesitancy. Most Chinese studies define vaccine hesitancy as a problem of vaccine safety and vaccine incident response and place accountability on the level of governance, such as regulation deficits and inappropriate crisis management. A first minority of studies tied vaccination hesitancy to unprofessional medical conduct and called for additional resources and enhanced physician qualifications. A second minority of studies positioned vaccination hesitancy as a problem of parental belief and pointed to the role of media, proposing enhanced communication and education. Chinese literature ties vaccine hesitancy primarily to vaccine safety and medical conduct. Compared to international research, parental concerns are underrepresented. The Chinese context of vaccination scandals notably frames the discussion of vaccination hesitancy and potential solutions, which stresses the importance of considering vaccination hesitancy in specific social and political contexts.

Vaccine hesitancy among Saudi parents and its determinants. Result from the WHO SAGE working group on vaccine hesitancy survey tool

OBJECTIVES

To assess the prevalence of vaccine hesitancy and its determinants among Saudi parents. In addition, we explored the relationship between vaccine hesitancy and child's immunization status. Methods: A cross-sectional study was conducted using interviews with parents visiting outpatient clinics at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia, between July 2017 and October 2018. The strategic advisory group of experts on immunization vaccine hesitancy survey was used. Results: A total of 500 parents were interviewed. Twenty percent of parents were hesitant to get their child vaccinated. Parents with higher educational levels were more vaccine hesitant (p less than 0.001). Among parents who reported hesitancy toward vaccination, 36% of children were not vaccinated fully for their age. Concerns related to vaccine safety were the most frequent reason (53%) reported by vaccine-hesitant parents. Negative beliefs toward vaccination seemed to be associated with increase hesitancy and incomplete vaccination status of children. In multivariate analyses, the main factors associated with both parents' hesitancy and incomplete vaccination status were believing that vaccines are ineffective (adjusted odds ratio [AOR]=28, 95% confidence interval [CI]: 7.9-102.3) and believing that vaccines are not important (AOR=27, 95% CI: 5.8-126). Conclusion: Vaccine hesitancy among parents in Kingdom of Saudi Arabia is a concern and is likely to influence the vaccination status of their children. Countering vaccine related concerns must be tailored, particularly in higher-educated groups.

Comparisons of Vaccine Hesitancy across Five Low- and Middle-Income Countries

Vaccine hesitancy is a continuum of behaviors ranging from delay in receipt to vaccination refusal. Prior studies have typically focused on high-income countries, where vaccine hesitancy is particularly prevalent in more affluent groups, but the relationship between socioeconomic status and vaccine hesitancy in Low- and Middle-Income Countries (LMICs) is less clear. The aim of this study was to describe vaccine hesitancy in five LMICs. Mothers of children in Sirajganj, Bangladesh (n = 60), Shanghai, China (n = 788), Addis Ababa, Ethiopia (n = 341), Guatemala City and Quetzaltenango, Guatemala (n = 767), and Chandigarh, India (n = 309), completed a survey between 2016 and 2018 using the WHO's 10-item Vaccine Hesitancy Scale. The scores of different constructs were compared across countries and by the mother's education level using linear regression models with generalized estimating equations. Compared to mothers in China, mothers in Bangladesh perceived less vaccination benefit (β: 0.56, P = 0.0001), however, mothers in Ethiopia (β: -0.54, P < 0.0001) and Guatemala (β: -0.74, P = 0.0004) perceived greater benefit. Education level was not significantly linked with vaccine hesitancy. Local circumstances are important to consider when developing programs to promote vaccines. We did not find consistent associations between education and vaccine hesitancy. More research is needed to understand socio-cultural influences on vaccine decision-making.