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

"The needle is already ready to go": communities' and health care professionals' perceptions of routine vaccination in Nunavik, Canada

Inuit living in the northern region of Nunavik continue to experience significant health inequalities, which are rooted in colonialism that still have repercussions on their health-related perceptions and practices, including vaccination. This study aimed to explore the perceptions and determinants of routine vaccination among the Inuit of Nunavik by describing factors influencing vaccination decisions from the perspective of community members and health professionals. Semi-structured interviews focusing on the perception of vaccination and experience with vaccination and health services were conducted with 18 Inuit and 11 non-Inuit health professionals. Using the socio-ecological model, factors acting at the community and public policy (e.g. rumours and misinformation about vaccination, language barrier), organisational (e.g. complexity of the vaccination process, staff turnover, lack of specialised vaccination workers and interpreters), and intrapersonal and interpersonal (e.g. past experiences with vaccination, vaccine attitudes, social norms) levels were identified as having an impact on vaccination decisions. Improving vaccination coverage in Nunavik requires a more global reflection on how to improve and culturally adapt the health care and services offered to the Inuit population.

Physicians' perspectives on COVID-19 vaccinations for children: a qualitative exploration in Ontario, Canada

OBJECTIVES

Parents' decisions to vaccinate their children against COVID-19 are complex and often informed by discussions with primary care physicians. However, little is known about physicians' perspectives on COVID-19 vaccinations for children or their experiences counselling parents in their decision-making. We explored physicians' experiences providing COVID-19 vaccination recommendations to parents and their reflections on the contextual factors that shaped these experiences.

DESIGN

We conducted an interpretive qualitative study using in-depth interviews. We analyzed the data using reflexive thematic analysis and a socioecological framework.

SETTING

This study involved primary care practices associated with The Applied Research Group for Kids (TARGet Kids!) primary care research network in the Greater Toronto Area, Ontario, Canada.

PARTICIPANTS

Participants were 10 primary care physicians, including family physicians, paediatricians and paediatric subspecialists.

RESULTS

Participants discussed elements at the individual level (their identity, role, and knowledge), the interpersonal level (their relationships with families, responsiveness to parents' concerns, and efforts to build trust) and structural level (contextual factors related to the evolving COVID-19 climate, health system pandemic response, and constraints on care delivery) that influenced their experiences providing recommendations to parents. Our findings illustrated that physicians' interactions with families were shaped by a confluence of their own perspectives, their responses to parents' perspectives, and the evolving landscape of the broader pandemic.

CONCLUSIONS

Our study underscores the social and relational nature of vaccination decision-making and highlights the multiple influences on primary care physicians' experiences providing COVID-19 vaccination recommendations to parents. Our findings offer suggestions for future COVID-19 vaccination programmes for children. Delivery of new COVID-19 vaccinations for children may be well suited within primary care offices, where trusting relationships are established, but physicians need support in staying knowledgeable about emerging information, communicating available evidence to parents to inform their decision-making and dedicating time for vaccination counselling.

Rethinking Barriers and Enablers in Qualitative Health Research: Limitations, Alternatives, and Enhancements

Explorations of barriers and enablers (or barriers and facilitators) to a desired health practice, implementation process, or intervention outcome have become so prevalent that they seem to be a default in much health services and public health research. In this article, we argue that decisions to frame research questions or analyses using barriers and enablers (B&Es) should not be default. Contrary to the strengths of qualitative research, the B&Es approach often bypasses critical reflexivity and can lead to shallow research findings with poor understanding of the phenomena of interest. The B&Es approach is untheorised, relying on assumptions of linear, unidirectional processes, universally desirable outcomes, and binary thinking which are at odds with the rich understanding of context and complexity needed to respond to the challenges faced by health services and public health. We encourage researchers to develop research questions using informed deliberation that considers a range of approaches and their implications for producing meaningful knowledge. Alternatives and enhancements to the B&Es approach are explored, including using 'whole package' methodologies; theories, conceptual frameworks, and sensitising ideas; and participatory methods. We also consider ways of advancing existing research on B&Es rather than doing 'more of the same': researchers can usefully investigate how a barrier or enabler works in depth; develop and test implementation strategies for addressing B&Es; or synthesise the B&Es literature to develop a new model or theory. Illustrative examples from the literature are provided. We invite further discussion on this topic.

Causes and Effects of COVID-19 Vaccine Hesitancy Among Pregnant Women and its Association with Adverse Maternal, Placental, and Perinatal Outcomes

Populations identified to be severely affected by COVID-19, such as pregnant patients, require special consideration in vaccine counseling, access, and provider education. Maternal infection with COVID-19 poses a significant risk to the maternal-fetal dyad with known adverse placenta destruction [1-5]. Despite the widespread access and availability of vaccinations, vaccine hesitancy continues to persist and is highly prevalent in pregnant populations [6-9]. Addressing the multitude of social ecological factors surrounding vaccine hesitancy can aid in providing holistic counseling [10]. However, such factors are foremost shaped by maternal concern over possible fetal effects from vaccination. While changes in policy can help foster vaccine access and acceptance, increasing global provider education and incorporation of motivational interviewing skills are the first steps towards increasing maternal acceptance.

The Social Ecology of Health Beliefs and Misinformation Framework: Examining the impact of misinformation on vaccine uptake through individual and sociological factors

BACKGROUND

Misinformation presents a critical concern for academic and public health discourse, particularly around vaccine response. Before the COVID-19 pandemic, vaccine hesitancy was responsible for decreased immunization uptake for vaccine-preventable diseases. Misinformation connected to the novel COVID-19 vaccine has further fueled vaccine hesitancy in Colorado and the United States. Our study brings together three different perspectives - physicians, public health professionals, and parents - to understand the impact of misinformation on vaccine uptake in Colorado. Our study proposes a framework for combining the Health Belief Model with the Socio-Ecological model to account for societal factors in healthcare decision making.

METHODS

Semi-structured interviews and focus groups with public health professionals, physicians, and parents (n = 31) were conducted in late spring and summer 2022. Data were coded inductively using thematic analysis. Identified themes were deductively categorized according to the Socio-Ecological Model and Health Belief Model.

RESULTS

Using a theoretical framework that combined the Health Belief Model and the Socio-Ecological Model, we identified seven factors that influenced vaccine hesitancy in Colorado. Intrapersonal factors included routine vaccine hesitancy connected to perceptions of severity and susceptibility, efficacy, and benefits and barriers to vaccine uptake; interpersonal factors included social networks; institutional factors included mass mediated platforms, portrayals of uncertainty, distrust in institutional sources of information, and political influences in vaccine decision making; and structural factors included economic barriers behind vaccine hesitancy.

CONCLUSIONS

Our study provides a unique, triangulated, post-positivist perspective on the role of misinformation in vaccine hesitancy in Colorado. The findings provide evidence that misinformation is an important barrier to vaccination uptake and can permeate multiple socio-ecological determinants/characteristics to influence vaccination behaviors including intrapersonal, interpersonal, institutional, and structural levels. We introduce the Social Ecology of Health Beliefs and Misinformation Framework to account for how misinformation may interrupt vaccine uptake.

Facilitators and barriers to COVID-19 testing in community and clinical settings: Lessons learned from Lesotho and Zambia

The sudden emergence of the coronavirus disease 2019 (COVID-19) had a devastating impact on health systems and population health globally. To combat the spread of COVID-19, countries enacted guidelines and safety measures, including testing, contact tracing, and quarantine. It was unclear the extent to which uptake of COVID-19 testing and other health initiatives would be accepted in countries with a history of dealing with widespread communicable disease transmission such as HIV or Tuberculosis. The objective of this study was to understand and compare the facilitators and barriers to COVID-19 testing at hospital sites in two rural communities in Lesotho and community spaces (referred to as hubs) in one urban community in Zambia during active phases of COVID-19 pandemic. Individual interviews and focus group discussions (FGDs) were held during March-October 2021 to explore facilitators and barriers to COVID-19 testing. FGDs with 105 community members and health care workers, and 16 individual interviews with key informants and four mystery shoppers were conducted across the two countries. In Zambia, four mystery shopper observations, and eight hub observations were also conducted. Individual country codebooks were developed and combined; thematic analyses were then conducted using the combined codebook. Findings were compared across the two countries, and most were consistent across the two countries. Two primary themes emerged that related to both barriers and facilitators: (1) structural conditions; (2) social implications and attitudes. The structural conditions that operated as barriers in both countries included public health isolation measures and misinformation. In Lesotho, the cost of tests was an additional barrier. The only structural facilitators were in Zambia where the community hubs were found to be accessible and convenient. The social implication barriers related to fear of isolation, stigma, and mental health implications because of quarantine, perceived pain of the test, and compromised privacy. Social facilitators that led to people testing included experiencing COVID-19 firsthand and knowing people who had died because of COVID-19. Across both countries, primary barriers and facilitators to COVID-19 related to structural conditions and social implications and attitudes. Public health measures can be at odds with social and economic realities; pandemic response should balance public health control and the socio-economic needs. Data from Zambia revealed that community-based settings have the potential to increase uptake of testing services. Community-based campaigns to normalize and reduce stigma for COVID-19 testing services are needed.

Psychological and Social Aspects of Vaccination Hesitancy-Implications for Travel Medicine in the Aftermath of the COVID-19 Crisis: A Narrative Review

Vaccines are an important tool of preventive medicine. Although organized vaccination programs have saved large populations from serious infectious diseases, there is a considerable part of the population who oppose vaccinations. In particular, anti-vaccination perceptions, among travelers to countries with endemic diseases, are a major public health concern. Although hesitancy towards vaccinations is not a novel phenomenon, it came back to the forefront during the fight against the COVID-19 pandemic. This review explores the etiology of anti-vaccination beliefs among travelers and draws conclusions about their impact on public health and society in general. For this purpose, a purposeful search for data on the causative factors of vaccine hesitancy and their impact on people's health was conducted. A descriptive analysis of the findings and conclusions regarding possible implications in health policy and clinical practice are presented. A fear of side effects, lack of credence in the necessity of vaccines, and mistrust of medical authorities are important causative factors. Their interplay shapes hesitancy towards vaccines. However, anti-vaccination beliefs can also be an aspect of a more general unconventional stance of life. Health care professionals and organizations must be ready to tackle vaccine hesitancy by making the necessary interventions. Correcting misconceptions about vaccinations is a prerequisite for ensuring personal and public health, especially in the context of a pandemic or epidemic. Moreover, ensuring the efficacy and safety of vaccines, especially in cases of modern technology applications, is a fundamental factor in addressing people's concerns about vaccines. For this purpose, medical authorities and organizations must provide accurate and clear information on vaccines so as to eliminate misinformation. Furthermore, clinicians should cultivate their communication skills in order to convey the appropriate messages to prospective recipients of vaccinations.

Behind closed doors: Protective social behavior during the COVID-19 pandemic

The success of personal non-pharmaceutical interventions as a public health strategy requires a high level of compliance from individuals in private social settings. Strategies to increase compliance in these hard-to-reach settings depend upon a comprehensive understanding of the patterns and predictors of protective social behavior. Social cognitive models of protective behavior emphasize the contribution of individual-level factors while social-ecological models emphasize the contribution of environmental factors. This study draws on 28 waves of survey data from the Understanding Coronavirus in America survey to measure patterns of adherence to two protective social behaviors-private social-distancing behavior and private masking behavior-during the COVID-19 pandemic and to assess the role individual and environmental factors play in predicting adherence. Results show that patterns of adherence fall into three categories marked by high, moderate, and low levels of adherence, with just under half of respondents exhibiting a high level of adherence. Health beliefs emerge as the single strongest predictor of adherence. All other environmental and individual-level predictors have relatively poor predictive power or primarily indirect effects.

Scale Development for COVID-19 Vaccine Hesitancy by Integration of Socio-Demographic and Psychological Factors

Vaccination is the most cost-effective way to maintain population health. However, it can only be effective if widespread acceptance is held. The efficacy of COVID-19 vaccines depends on their favor. When countries start to vaccinate their citizens, there is a certain level of skepticism about the effectiveness of the vaccines. The hesitancy study on vaccines has gained momentum following the pandemic. However, few studies have examined the link between the psychological and sociodemographic factors influencing the fit. This paper proposes integrating the concepts of the information systems success and stimulus-organism-response into a cognitive fit theory framework to explore the integration of psychological and sociodemographic factors in the receivers' reactions (n = 1510). This study analyses the factors that influence the hesitancy of vaccines and the public's refusal in Asia and Europe. Receivers' reactions were assessed to various stimuli and we explored the link between psychological and sociodemographic elements and the concept of fit. Two surveys were conducted following the scale development of Mackenzie. The first was to develop the fit scale, while the second was to validate the fit scale. The results of the second survey were analyzed using structural equation modelling. The results indicate that the scale's fit development is valid and reliable. The quality of the vaccine information, the psychological characteristics of the vaccine system, and vaccine receivers' satisfaction are also beneficial factors for emotional and cognitive fit. Maintaining the vaccines' quality and efficiency can help improve the fit between sociodemographic and psychological characteristics. It can also enhance receivers' satisfaction and encourage continued vaccine administration. This study is regarded as one of the first to examine and develop an emotional and cognitive fit scale for practitioners and researchers.

Social and ideological determinants of COVID-19 vaccination status in Spain

OBJECTIVES

This study analysed the association between social and ideological determinants with COVID-19 vaccine accessibility and hesitancy in the Spanish adult population.

STUDY DESIGN

This was a repeated cross-sectional study.

METHODS

The data analysed are based on monthly surveys conducted by the Centre for Sociological Research between May 2021 and February 2022. Individuals were classified according to their COVID-19 vaccination status into (1) vaccinated (reference group); (2) willing to vaccinate but not vaccinated, proxy of lack of vaccine accessibility; and (3) hesitant, proxy of vaccine hesitancy. Independent variables included social (educational attainment, gender) and ideological determinants (voting in the last elections, importance attached to the health vs the economic impact of the pandemic, and political self-placement). We estimated odds ratio (OR) and 95% confidence interval (CI) conducting one age-adjusted multinomial logistic regression model for each determinant and then stratified them by gender.

RESULTS

Both social and ideological determinants had a weak association with the lack of vaccine accessibility. Individuals with medium educational attainment had higher odds of vaccine hesitancy (OR = 1.44, CI 1.08-1.93) compared with those with high educational attainment. People self-identified as conservative (OR = 2.90; CI 2.02-4.15) and those who prioritised the economic impact (OR = 3.80; CI 2.62-5.49) and voted for parties opposed to the Government (OR = 2.00; CI 1.54-2.60) showed higher vaccine hesitancy. The stratified analysis showed a similar pattern for both men and women.

CONCLUSIONS

Considering the determinants of vaccine uptake and hesitancy could help to design strategies that increase immunisation at the population level and minimise health inequities.

Reaching late adopters: factors influencing COVID-19 vaccination of Marshallese and Hispanic adults

BACKGROUND

Marshallese and Hispanic communities in the United States have been disproportionately affected by COVID-19. Identifying strategies to reach late vaccine adopters is critical for ongoing and future vaccination efforts. We utilized a community-engaged approach that leveraged an existing community-based participatory research collaborative of an academic healthcare organization and Marshallese and Hispanic faith-based organizations (FBO) to host vaccination events.

METHODS

Bilingual Marshallese and Hispanic study staff conducted informal interviews with 55 participants during the 15-minute post-vaccination observation period and formal semi-structured interviews with Marshallese (n = 5) and Hispanic (n = 4) adults post-event to assess the implementation of community vaccine events at FBOs, with a focus on factors associated with the decision to attend and be vaccinated. Formal interview transcripts were analyzed using thematic template coding categorized with the socio-ecological model (SEM). Informal interview notes were coded via rapid content analysis and used for data triangulation.

RESULTS

Participants discussed similar factors influencing attitudes and behaviors toward receiving the COVID-19 vaccine. Themes included: (1) intrapersonal - myths and misconceptions, (2) interpersonal - protecting family and family decision-making, (3) community - trust of community location of events and influence of FBO members and leaders, (4) institutional - trust in a healthcare organization and bilingual staff, and (5) policy. Participants noted the advantages of vaccination delivery at FBOs, contributing to their decision to attend and get vaccinated.

CONCLUSIONS

The following strategies may improve vaccine-related attitudes and behaviors of Marshallese and Hispanic communities not only for the COVID-19 vaccine but also for other preventive vaccinations: 1) interpersonal-level - develop culturally-focused vaccine campaigns targeting the family units, 2) community-level - host vaccination events at convenient and/or trusted locations, such as FBOs, and engage community and/or FBO formal or lay leaders as vaccine ambassadors or champions, and 3) institutional-level - foster trust and a long-term relationship with the healthcare organization and provide bilingual staff at vaccination events. Future research would be beneficial to investigate the effects of replicating these strategies to support vaccine uptake among Marshallese and Hispanic communities.