Vaccine message framing and parents' intent to immunize their infants for MMR

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

Understanding communication in community engagement for maternal and newborn health programmes in low- and middle-income countries: a realist review

As community engagement (CE) is implemented for sustainable maternal and newborn health (MNH) programming, it is important to determine how these approaches work. Low- and middle-income countries (LMICs) have become a particular focus for MNH CE activities due to their high burden of maternal and neonatal deaths. MNH messaging and communication to engage communities are likely to differ by context, but how these approaches are actually developed and implemented within CE is not well understood. Understanding how communications in CE actually work is vital in the translation of learnings across programmes and to inform future projects. The purpose of this realist review is to describe how, why, to what extent and for whom communications in CE contribute to MNH programming in LMICs. After searching academic databases, grey literature and literature suggested by the expert advisory committee, documents were included if they described the CE communication processes/activities used for MNH programming in an LMIC. Relevant documents were assessed for richness (depth of insight) and rigor (trustworthiness and coherence of data/theories). Data were extracted as context-mechanism-outcome configurations (CMOCs) and synthesized into demi-regularities to contribute to theory refinement. After screening 416 records, 45 CMOCs were extracted from 11 documents. This informed five programme theories explaining that communications in CE for an MNH programme work when: communities are actively involved throughout the programme, the messaging and programme are acceptable, communication sources are trusted, the community has a reciprocal relationship with the programme and the community sees value in the programme. While these findings reflect what is often anecdotally known in CE or acknowledged in communications theory, they have implications for policy, practice and research by highlighting the importance of centring the community's needs and priorities throughout the stages of developing and implementing communications for CE in MNH.

Say it right: measuring the impact of different communication strategies on the decision to get vaccinated

BACKGROUND

Vaccine hesitancy is a concerning menace to the control of vaccine-preventable diseases. Effective health communication could promote an overall understanding of the importance, risks, and benefits of vaccination and reduce vaccine hesitancy.

METHODS

In this survey, four fictitious newspaper articles addressing an emerging bogus disease and its vaccine were randomly assigned to participants. The first version focused on information about the disease; the second was akin to the first, including a case description and image. The third version focused on vaccine safety/efficacy; the fourth version was like the third, including a case description and image. After reading a single version of the article, participants responded if they would take the vaccine and if they would vaccinate their children. We used chi-squared tests for comparisons and investigated interactions with vaccine-hesitant attitudes.

RESULTS

We included 5233 participants between August/2021 and January/2022; 790 were caregivers of a child ≤ 5 years old, and 15% had prior vaccine hesitancy. Although most declared intention to take the vaccine, the percentage was highest among those exposed to the newspaper article focusing on the vaccine safety/efficacy with the case description and picture (91%; 95% confidence interval 89-92%), and lowest among participants exposed to the article focusing on the disease with no case description (84%; 95% confidence interval 82-86%). Similar trends were observed in the intention of offspring vaccination. We found evidence of effect modification by vaccine-hesitant attitudes, with a higher impact of communication focusing on vaccine safety/efficacy compared to that focusing on disease characteristics among hesitant participants.

CONCLUSION

Communication strategies focusing on different aspects of the disease-vaccine duet may impact vaccine hesitancy, and storytelling/emotive imagery descriptions may improve risk perception and vaccine uptake. Moreover, the effect of message framing strategies may differ according to previous vaccine hesitant attitudes.

Personal risk or societal benefit? Investigating adults' support for COVID-19 childhood vaccination

Parental hesitancy poses a serious threat to the success of the COVID-19 childhood vaccination campaign. We investigate whether adults' opinions on childhood vaccination can be influenced via two survey experiments in Italy (n = 3,633 participants) and the UK (n = 3,314 participants). Respondents were randomly assigned to: a "risk treatment" that highlighted the potential risks of COVID-19 to a child, a "herd immunity treatment" that emphasized the community benefits of pediatric vaccination, or a control message. Participants' probability of supporting COVID-19 childhood vaccination was then assessed on a 0-100 scale. We find that the "risk treatment" reduced the proportion of Italian parents strongly against vaccination by up to 29.6 %, while increasing the proportion of neutral parents by up to 45.0 %. The "herd immunity treatment", instead, was only effective among non-parents, resulting in a lower proportion of individuals against pediatric vaccination and a higher proportion of individuals in favor (both shifted by around 20 %).

Mothers' intentions to vaccinate their children for COVID-19

Parents' intentions to vaccinate their children is an important area of investigation in light of the COVID-19 pandemic. There is a growing body of research examining factors that influence parents' vaccine intentions. The current study investigated factors that would influence maternal intent to vaccinate their children for COVID-19, shortly before the CDC approved vaccines for children 11 and younger. We had a sample of n = 176 mothers (Mchildage = 71.63 months, 52% White) from California fill out an online survey during February-April 2021. Our results suggest that perceived COVID-19 threat predicts mothers' intention to vaccinate their children (b = 0.370, p < 0.001), controlling for mothers' age, socioeconomic status, race, and child age. Child age (b = 0.027, p = 0.008), SES (b = 0.396, p = 0.018), and child previous flu shot (b = 0.725, p < 0.001) also positively predicted mothers' intention to vaccinate their children. Results are discussed in light of prior research on maternal vaccine intentions and hesitancy.

Misinformation, infighting, backlash, and an 'endless' recovery; policymakers recount challenges and mitigating measures after a vaccine scare in the Philippines

Background

Vaccine scares undermine longstanding global health achievements. Remarkably little data has documented the lived experiences of policymakers working amidst vaccine scares and navigating their fallout. As a result, chances and challenges of large-scale national recuperation efforts are poorly understood.

Objective

This study aims to explore the perspectives of policymakers involved in ongoing efforts to boost vaccine confidence in the Philippines following a 2017 Dengvaxia scare and the current COVID-19 pandemic.

Methods

Between August and November 2020, we conducted 19 semi-structured narrative interviews with purposively selected policymakers from governmental agencies and non-governmental organizations in the Philippines. Interviews were conducted online, transcribed, and analyzed following the tenets of reflexive thematic analysis.

Results

We present results as an emerging model that draws on a chronology conveyed by policymakers in their own words. The Dengvaxia scare proved ‘a decisive wedge’ that splintered Filipino society and pitted governmental agencies against one another. The scare stoked distorted vaccination narratives, which were ‘accelerated rapidly’ via social media, and ignited feelings of uncertainty among policymakers of how to convey clear, accurate health messaging and how to prevent drops in care-seeking more broadly.

Conclusions

Efforts to regain trust placed exceptional burdens on an already-strained health system. Respondent-driven recommendations on how to reinforce vaccine confidence and improve vaccination rollout include: developing clear vaccine messages, fostering healthcare providers’ and policymakers’ communication skills, and rebuilding trust within, toward and across governmental agencies. Further research on how to build enabling environments and rebuild trust in and across institutions remains paramount.

Flattening the COVID-19 curve: Emotions mediate the effects of a persuasive message on preventive action

Introduction

Across four countries (Canada, USA, UK, and Italy), we explored the effects of persuasive messages on intended and actual preventive actions related to COVID-19, and the role of emotions as a potential mechanism for explaining these effects.

Methods

One thousand seventy-eight participants first reported their level of concern and emotions about COVID-19 and then received a positive persuasive text, negative persuasive text, or no text. After reading, participants reported their emotions about the pandemic and their willingness to take preventive action. One week following, the same participants reported the frequency with which they engaged in preventive action and behaviors that increased the risk of contracting COVID-19.

Results

Results revealed that the positive persuasive text significantly increased individuals' willingness to and actual engagement in preventive action and reduced risky behaviors 1 week following the intervention compared to the control condition. Moreover, significant differences were found between the positive persuasive text condition and negative persuasive text condition whereby individuals who read the positive text were more willing and actually engaged in more preventive action compared to those who read the negative text. No differences were found, however, at the 1-week follow-up for social distancing and isolation behaviors. Results also revealed that specific discrete emotions mediated relations between the effects of the texts and preventive action (both willing and actual).

Discussion

This research highlights the power of educational interventions to prompt behavioral change and has implications for pandemic-related interventions, government policy on health promotion messages, and future research.

Overcoming Vaccine Hesitancy for Future COVID-19 and HIV Vaccines: Lessons from Measles and HPV Vaccines

BACKGROUND

The discovery of vaccines significantly reduced morbidity and mortality of infectious diseases and led to the elimination and eradication of some. Development of safe and effective vaccines is a critical step to the control of infectious diseases; however, there is the need to address vaccine hesitancy because of its potential impact on vaccine uptake.

METHODS

We conducted a narrative review of studies on interventions to address measles and human papillomavirus vaccine hesitancy. We discussed how lessons learned from these studies could be applied towards COVID-19 and future human immunodeficiency virus vaccines.

RESULTS

We found that there are several successful approaches to improving vaccine acceptance. Interventions should be context specific and build on the challenges highlighted in various settings.

CONCLUSION

Strategies could be used alone or in combination with others. The most successful interventions directly targeted the population for vaccination. Use of financial incentives could be a potential tool to improve vaccine uptake.

Think about your friends and family: The disparate impacts of relationship-centered messages on privacy concerns, protective health behavior, and vaccination against Covid-19

Objective

To understand which factors affect how willing people are to share their personal information to combat the Covid-19 pandemic, and compare them to factors that affect other public health behaviors.

Method

We analyze data from three pre-registered online experiments conducted over eight months during the Covid-19 pandemic in the United States (April 3 2020 –November 25, 2020). Our primary analysis tests whether support for data sharing and intention to practice protective behavior increase in response to relationship-centered messages about prosociality, disease spread, and financial hardship. We then conduct a secondary correlational analysis to compare the demographic and attitudinal factors associated with willingness to share data, protective behavior, and intent to get vaccinated. Our sample (N = 650) is representative to socio-demographic characteristics of the U.S. population.

Results

We find the altruistic condition increased respondents’ willingness to share data. In our correlational analysis, we find interactive effects of political ID and socio-demographic traits on likelihood to share data. In contrast, we found health behavior was most strongly associated with political ID, and intent to vaccinate was more associated with socio-demographic traits.

Conclusions

Our findings suggest that some public health messaging, even when it is not about data sharing or privacy, may increase public willingness to share data. We also find the role of socio-demographic factors in moderating the effect of political party ID varies by public health behavior.

The effect of herd immunity thresholds on willingness to vaccinate

Throughout the COVID-19 pandemic, media and policymakers openly speculated about the number of immune citizens needed to reach a herd immunity threshold. What are the effects of such numerical goals on the willingness to vaccinate? In a large representative sample (N = 1540) of unvaccinated Swedish citizens, we find that giving a low (60%) compared to a high (90%) threshold has direct effects on beliefs about reaching herd immunity and beliefs about how many others that will get vaccinated. Presenting the high threshold makes people believe that herd immunity is harder to reach (on average about half a step on a seven-point scale), compared to the low threshold. Yet at the same time, people also believe that a higher number of the population will get vaccinated (on average about 3.3% more of the population). Since these beliefs affect willingness to vaccinate in opposite directions, some individuals are encouraged and others discouraged depending on the threshold presented. Specifically, in mediation analysis, the high threshold indirectly increases vaccination willingness through the belief that many others will get vaccinated (B = 0.027, p = 0.003). At the same time, the high threshold also decreases vaccination willingness through the belief that the threshold goal is less attainable (B = -0.053, p < 0.001) compared to the low threshold condition. This has consequences for ongoing COVID-19 vaccination and future vaccination campaigns. One message may not fit all, as different groups can be encouraged or discouraged from vaccination.

An Online Experiment of NHS Information Framing on Mothers’ Vaccination Intention of Children against COVID-19

Children under the age of 5, will likely all be offered vaccination against SARS-CoV-2 soon. Parental concerns over vaccination of children are long standing and could impede the success of a vaccination campaign. In the UK, a trusted source to inform vaccination choices is the NHS website. Here we used a randomized controlled experiment of framing effects in NHS information content for COVID-19 and flu with 550 mothers under the age of 5. We compared both vaccination offers following two commonly used frames in vaccination informational campaigns: alerting to the risks of no vaccination for the child itself vs. those in their community. We find that vaccination intention was twice as high when risks to the child are emphasized, relative to risks to the community. Exploratory analyses suggest that these effects may differ between white and non-white mothers. Whilst communication directed at adult vaccination against COVID-19 generally focuses on risks of infecting others, communication about vaccination of children may benefit from emphasizing risks to the children themselves. This pattern is in line with flu vaccination research from pre-COVID-19 times.

Communications to Promote Interest and Confidence in COVID-19 Vaccines

PURPOSE

Communicating about COVID-19 vaccine side effects and efficacy is crucial for promoting transparency and informed decision-making, but there is limited evidence on how to do so effectively.

DESIGN

A within-subjects experiment.

SETTING

Online survey from January 21 to February 6, 2021.

SUBJECTS

596 US Veterans and 447 non-Veterans.

INTERVENTION

5 messages about COVID-19 vaccine side effects and 4 messages about COVID-19 vaccine efficacy.

MEASURES

COVID-19 vaccine interest (1 = "I definitely do NOT want the vaccine" to 7 = "I definitely WANT the vaccine" with the midpoint 4 = "Unsure"). Confidence about COVID-19 vaccine efficacy (1= "Not at all confident," 2 = "Slightly confident," 3 = "Somewhat confident," 4 = "Moderately confident," 5 = "Extremely confident").

RESULTS

Compared to providing information about side effects alone (M = 5.62 [1.87]), messages with additional information on the benefits of vaccination (M = 5.77 [1.82], P < .001, d_z = .25), reframing the likelihood of side effects (M = 5.74 [1.84], P < .001, d_z = .23), and emphasizing that post-vaccine symptoms indicate the vaccine is working (M = 5.72 [1.84], P < .001, d_z = .17) increased vaccine interest. Compared to a vaccine efficacy message containing verbal uncertainty and an efficacy range (M = 3.97 [1.25]), messages conveying verbal certainty with an efficacy range (M = 4.00 [1.24], P = .042, d_z=.08), verbal uncertainty focused on the upper efficacy limit (M = 4.03 [1.26], P < .001, d_z = .13), and communicating the point estimate with certainty (M = 4.02 [1.25], P < .001, d_z = .11) increased confidence. Overall, Veteran respondents were more interested (M_Veterans = 5.87 [1.72] vs M_NonVeterans = 5.45 [2.00], P < .001, d = .22) and confident (M_Veterans = 4.13 [1.19] vs M_NonVeterans = 3.84 [1.32], P < .001, d = .23) about COVID-19 vaccines than non-Veterans.

CONCLUSIONS

These strategies can be implemented in large-scale communications (e.g., webpages, social media, and leaflets/posters) and can help guide healthcare professionals when discussing vaccinations in clinics to promote interest and confidence in COVID-19 vaccines.

Virtual reality reduces COVID-19 vaccine hesitancy in the wild: a randomized trial

Vaccine hesitancy poses one of the largest threats to global health. Informing people about the collective benefit of vaccination has great potential in increasing vaccination intentions. This research investigates the potential for engaging experiences in immersive virtual reality (VR) to strengthen participants' understanding of community immunity, and therefore, their intention to get vaccinated. In a pre-registered lab-in-the-field intervention study, participants were recruited in a public park (tested: [Formula: see text], analyzed: [Formula: see text]). They were randomly assigned to experience the collective benefit of community immunity in a gamified immersive virtual reality environment ([Formula: see text] of sample), or to receive the same information via text and images ([Formula: see text] of sample). Before and after the intervention, participants indicated their intention to take up a hypothetical vaccine for a new COVID-19 strain (0-100 scale) and belief in vaccination as a collective responsibility (1-7 scale). The study employs a crossover design (participants later received a second treatment), but the primary outcome is the effect of the first treatment on vaccination intention. After the VR treatment, for participants with less-than-maximal vaccination intention, intention increases by 9.3 points (95% CI: 7.0 to [Formula: see text]). The text-and-image treatment raises vaccination intention by 3.3 points (difference in effects: 5.8, 95% CI: 2.0 to [Formula: see text]). The VR treatment also increases collective responsibility by 0.82 points (95% CI: 0.37 to [Formula: see text]). The results suggest that VR interventions are an effective tool for boosting vaccination intention, and that they can be applied "in the wild"-providing a complementary method for vaccine advocacy.

Don't get it or don't spread it: comparing self-interested versus prosocial motivations for COVID-19 prevention behaviors

COVID-19 prevention behaviors may be seen as self-interested or prosocial. Using American samples from MTurk and Prolific (total n = 6850), we investigated which framing is more effective-and motivation is stronger-for fostering prevention behavior intentions. We evaluated messaging that emphasized personal, public, or personal and public benefits of prevention. In initial studies (conducted March 14-16, 2020), the Public treatment was more effective than the Personal treatment, and no less effective than the Personal + Public treatment. In additional studies (conducted April 17-30, 2020), all three treatments were similarly effective. Across all these studies, the perceived public threat of coronavirus was also more strongly associated with prevention intentions than the perceived personal threat. Furthermore, people who behaved prosocially in incentivized economic games years before the pandemic had greater prevention intentions. Finally, in a field experiment (conducted December 21-23, 2020), we used our three messaging strategies to motivate contact-tracing app signups (n = 152,556 newsletter subscribers). The design of this experiment prevents strong causal inference; however, the results provide suggestive evidence that the Personal + Public treatment may have been more effective than the Personal or Public treatment. Together, our results highlight the importance of prosocial motives for COVID-19 prevention.

Nudging toward vaccination: a systematic review

Background

Vaccine hesitancy (VH) and the global decline of vaccine coverage are a major global health threat, and novel approaches for increasing vaccine confidence and uptake are urgently needed. ‘Nudging’, defined as altering the environmental context in which a decision is made or a certain behaviour is enacted, has shown promising results in several health promotion strategies. We present a comprehensive synthesis of evidence regarding the value and impact of nudges to address VH.

Methods

We conducted a systematic review to determine if nudging can mitigate VH and improve vaccine uptake. Our search strategy used Medical Subject Headings (MeSH) and non-MeSH terms to identify articles related to nudging and vaccination in nine research databases. 15 177 titles were extracted and assessed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The final list of included articles was evaluated using the Mixed Methods Appraisal Tool and the Grading of Recommendations, Assessment, Development and Evaluations framework.

Findings

Identified interventions are presented according to a framework for behaviour change, MINDSPACE. Articles (n=48) from 10 primarily high-income countries were included in the review. Nudging-based interventions identified include using reminders and recall, changing the way information is framed and delivered to an intended audience, changing the messenger delivering information, invoking social norms and emotional affect (eg, through storytelling, dramatic narratives and graphical presentations), and offering incentives or changing defaults. The most promising evidence exists for nudges that offer incentives to parents and healthcare workers, that make information more salient or that use trusted messengers to deliver information. The effectiveness of nudging interventions and the direction of the effect varies substantially by context. Evidence for some approaches is mixed, highlighting a need for further research, including how successful interventions can be adapted across settings.

Conclusion

Nudging-based interventions show potential to increase vaccine confidence and uptake, but further evidence is needed for the development of clear recommendations. The ongoing COVID-19 pandemic increases the urgency of undertaking nudging-focused research.

PROSPERO registration number

CRD42020185817.

Scared, powerless, insulted and embarrassed: hesitancy towards vaccines among caregivers in Cavite Province, the Philippines

BACKGROUND

Several studies have highlighted that vaccine hesitancy (VH) is among the most important threats to global health, especially in low- and middle-income countries, including the Philippines. However, there is a dearth of literature exploring family experiences of-or concerns related to-childhood vaccinations that gives voice to vaccine hesitant caregivers (VHCs) of small children. Here, we present insights from VHCs from the Philippines.

METHODS

This research draws on in-depth interviews (IDIs) with 44 VHCs who had previously delayed or refused vaccination for their children in rural and urban communities in Cavite Province, the Philippines. Amid the COVID-19 pandemic, we conducted IDIs via an online platform of the respondents' choosing (ie, Facebook messenger call, Skype and Zoom). All interviews were recorded, transcribed, translated and analysed drawing from the tenets of constructivist grounded theory. We use the social ecological model to structure our results.

RESULTS

Among the reasons for delay or refusal of childhood vaccinations, a fear of side effects emerged as the most salient concern, exacerbated by previous negative experiences (including trauma) from a dengue vaccine controversy in 2017. Respondents cited the dengue vaccine controversy as they expressed reluctance (regarding any new vaccines) and suspicion (towards school-based vaccination, the distribution channel used for the dengue vaccine). Heads of households opposing vaccines, perceptions that vaccines are non-essential and influences from the social and traditional media or neighbours contributed to further refusal and delay. Upon probing, VHCs recounted health system concerns particularly with regards to healthcare workers who are sometimes unable to answer their questions and can be dismissive or disrespectful regarding caregivers' concerns.

CONCLUSION

Understanding VH from the lens of VHCs highlights pathways for interventions to regain trust and bolster confidence towards vaccines. Our findings may serve as linchpins in the development of VH interventions aiming at changing behaviour on a population scale.

Emphasize personal health benefits to boost COVID-19 vaccination rates

The rapid development of COVID-19 vaccines is a tremendous scientific response to the current global pandemic. However, vaccines per se do not save lives and restart economies. Their success depends on the number of people getting vaccinated. We used a survey experiment to examine the impact on vaccine intentions of a variety of public health messages identified as particularly promising: three messages that emphasize different benefits from the vaccines (personal health, the health of others, and the recovery of local and national economies) and one message that emphasizes vaccine safety. Because people will likely be exposed to multiple messages in the real world, we also examined the effect of these messages in combination. Based on a nationally quota representative sample of 3,048 adults in the United States, our findings suggest that several forms of public messages can increase vaccine intentions, but messaging that emphasizes personal health benefits had the largest impact.

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.

Message Framing Effects on Individuals' Social Distancing and Helping Behavior During the COVID-19 Pandemic

This research responds to urgent calls to fill knowledge gaps on COVID-19 (new coronavirus) in communicating social distancing messages to the public in the most convincing ways. The authors explore the effectiveness of framing social distancing messages around prosocial vs. self-interested appeals in driving message compliance and helping behavior. The results show that when a message emphasizes benefits for everyone in society, rather than solely for the individual, citizens find the message more persuasive to engage in social distancing, and also more motivating to help others. The results further demonstrate that the proposed effects are higher for individuals who have a lower locus of control and lower fear of coronavirus as prosocial messages lead them to feel a joint responsibility in protecting from the pandemic. Theoretical and practical implications of the results are discussed.

The Role of Emotional Competences in Parents' Vaccine Hesitancy

The role of parents’ emotional competencies on vaccine hesitancy and decision making has been seldom examined. Two studies investigated the relationship between parents’ attitudes towards childhood vaccines and self-reported behavior (Study 1) and between parents’ emotional competence and attitudes towards vaccines (Study 2). In Study 1, predictors of temporal, partial, or complete vaccine refusal (having voluntarily postponed/forgone some/all vaccines) were examined in 2778 parents. In Study 2, psychological predictors of the attitude towards vaccines were examined in 593 parents, using the Profile of Emotional Competence and the valence of mental images spontaneously associated with the term “vaccine”. In Study 1, attitudes were aggregated in three independent factors (concerns about vaccine safety; diseases prevented by vaccines; and naturalistic views) that independently predicted vaccine refusal. In Study 2, a significant mediational analysis showed a positive indirect effect of intrapersonal emotional competences on attitudes towards vaccines, through mental images associated with the word “vaccine”. Parents’ intrapersonal emotional competences affected all dimensions of attitudes towards vaccines, suggesting that being able to manage, identify, and recognize one’s own emotions is central to vaccine acceptance. These findings suggest that intervention strategies, rather than stressing the pro-social benefits of vaccinating, should focus on aspects related to one’s own emotions.

The Model of "Informed Refusal" for Vaccination: How to Fight against Anti-Vaccinationist Misinformation without Disregarding the Principle of Self-Determination

Vaccines are arguably a public health success story as well as an incredibly cost-effective medical resource. Despite this, worldwide concerns about their safety are growing, with the risk of increased morbidity and mortality in vaccine-preventable diseases because of vaccine refusal. The global political trend in developed countries is to increasingly reduce mandates and the compulsory nature of vaccination programs. This is due to strong opposition from anti-vaccination movements and groups. While these have existed since the beginnings of vaccinology, they have recently gained a strong foothold through massive exploitation of the media and especially the internet. This has led to widespread misinformation and greater difficulty for governments and health institutions in dealing with parents’ concerns and misconceptions. Common strategies in order to maintain a high degree of public acceptance of vaccines include the enhancement of adverse effect reporting systems, the enrichment of scientific literature, and the dissemination of targeted information to parents and health care providers. Vaccine risk perception, in fact, largely exceeds the evidence and is linked to well-known general population cognitive bias, which must be recognized and corrected. Although there is no doubt about the convenience of universal vaccination, a lively international debate is underway with regard to the legitimacy of mandatory vaccination programs. Most scientists agree that the individual’s right to self-determination should be preserved. The only way to simultaneously protect the right to health is to introduce an informed refusal model, which aims to guarantee the highest coverage rates for vaccination.

The Dizziness of Freedom: Understanding and Responding to Vaccine Anxieties

The rise in vaccine hesitancy in high-income countries has led some to recommend that certain vaccinations be made compulsory in states where they are currently voluntary. In contrast, I contend that legal coercion is generally inappropriate to address the complex social and psychological phenomenon of vaccine anxieties.

Words matter: political and gender analysis of speeches made by heads of government during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has put a spotlight on political leadership around the world. Differences in how leaders address the pandemic through public messages have practical implications for building trust and an effective response within a country.

METHODS

We analysed the speeches made by 20 heads of government around the world (Bangladesh, Belgium, Bolivia, Brazil, Dominican Republic, Finland, France, Germany, India, Indonesia, New Zealand, Niger, Norway, Russia, South Africa, Scotland, Sint Maarten, United Kingdom, United States and Taiwan) to highlight the differences between men and women leaders in discussing COVID-19. We used an inductive analytical approach, coding speeches for specific themes based on language and content.

FINDINGS

Five primary themes emerged across a total of 122 speeches on COVID-19, made by heads of government: economics and financial relief, social welfare and vulnerable populations, nationalism, responsibility and paternalism, and emotional appeals. While all leaders described the economic impact of the pandemic, women spoke more frequently about the impact on the individual scale. Women leaders were also more often found describing a wider range of social welfare services, including: mental health, substance abuse and domestic violence. Both men and women from lower-resource settings described detailed financial relief and social welfare support that would impact the majority of their populations. While 17 of the 20 leaders used war metaphors to describe COVID-19 and the response, men largely used these with greater volume and frequency.

CONCLUSION

While this analysis does not attempt to answer whether men or women are more effective leaders in responding to the COVID-19 pandemic, it does provide insight into the rhetorical tools and types of language used by different leaders during a national and international crisis. This analysis provides additional evidence on the differences in political leaders' messages and priorities to inspire citizens' adhesion to the social contract in the adoption of response and recovery measures. However, it does not consider the influence of contexts, such as the public audience, on leaders' strategic communication approaches.

Does education about local vaccination rates and the importance of herd immunity change US parents' concern about measles?

It is unclear how broadly aware parents are of the concept of herd immunity and whether parents consider community benefits of vaccination when making decisions about their child's vaccinations. We aimed to determine whether educating parents about community-level benefits of measles, mumps, and rubella (MMR) vaccination and local vaccination rates would impact concern about their child's risk of measles and risk of a measles outbreak. We conducted an electronic survey among Minnesota parents of children aged 6-18 years in August 2016. We assessed baseline knowledge of herd immunity, asked participants to estimate MMR vaccination coverage in their county, and asked participants to estimate the minimum coverage needed to prevent measles outbreaks. We then delivered a short, educational intervention via the survey to inform participants about the benefits of herd immunity, the actual MMR vaccination coverage in their county, and that at least 95% MMR vaccination coverage is needed to prevent measles outbreaks. Pre- and post-intervention, participants were asked to report how concerned they were that their child might get measles. We used logistic regression models to assess factors associated with awareness of herd immunity, change in concern about one's child's measles risk, and overall concern for a measles outbreak. Among 493 participants, 67.8% were aware of herd immunity at baseline. Post-intervention, 40.2% (n = 198) of parents learned that MMR vaccination rates in their county were higher than they expected. All participants found out that their county MMR rates were lower than the measles herd immunity threshold of 95%. Overall, 27.0% (n = 133) of participants reported an increase in concern that their child might get measles after learning about local vaccination coverage and the coverage needed to achieve herd immunity. We found that our short, educational intervention aimed to increase awareness about herd immunity and local vaccination led to an increase in concern about disease risk among less than a third of parents.

Evaluating prosocial COVID-19 messaging frames: Evidence from a field study on Facebook

The rapid spread of COVID-19 has emphasized the need for effective health communications to coordinate individual behavior and mitigate disease transmission. Facing a pandemic, individuals may be driven to adopt public health recommendations based on both self-interested desires to protect oneself and prosocial desires to protect others. Although messages can be framed around either, existing research from the social sciences has offered mixed evidence regarding their relative efficacy. Informing this dialogue, in the current study we report on the findings of a field experiment (N = 25,580) conducted March 21–22 on Facebook during the critical initial weeks of the COVID-19 outbreak in the United States. We observed that ad messages using a distant prosocial frame (“protect your community”) were in fact significantly less effective than those using a self-focused frame (“protect yourself”) in eliciting clickthroughs to official CDC recommendations. However, ad messages with a close prosocial frame (“protect your loved ones”) were equally effective as the self-focused frame. These findings catalog the differential efficacy of ad messaging strategies during the early stages of the coronavirus pandemic.

Addressing Parental Vaccine Hesitancy towards Childhood Vaccines in the United States: A Systematic Literature Review of Communication Interventions and Strategies

Parental vaccine hesitancy is becoming an increasingly important public health concern in the United States. In March 2020, an assessment of the latest CDC National Immunization Survey data found that more than one-third of U.S. children between the ages of 19 and 35 months were not following the recommended early childhood immunization schedule. Furthermore, a 2019 national survey found that approximately 1 in 4 parents reported serious concerns towards vaccinating their children. Vaccine hesitancy is now associated with a decrease in vaccine coverage and an increase in vaccine-preventable disease outbreaks and epidemics in the United States. Many studies have focused on understanding and defining the new socio-medical term, vaccine hesitancy; few have attempted to summarize past and current health communication interventions and strategies that have been successful or unsuccessful in tackling this growing phenomenon. This systematic literature review will attempt to aid public health professionals with a catalogue of health communication interventions and strategies to ultimately address and prevent parental vaccine hesitancy in the long term. Out of 1239 search results, a total of 75 articles were included for analysis, ranging from systematic reviews, quantitative surveys, and experimental designs to ethnographic and qualitative studies. For the presentation of results, a taxonomy was used to organize communication interventions according to their intended purpose. The catalogue of interventions was further broken down into specific components and themes that were identified in the literature as essential to either the success or failure in preventing and addressing parental vaccine hesitancy towards childhood vaccines.

A Select Bibliography of Actions to Promote Vaccine Literacy: A Resource for Health Communication

In this bibliography, the researchers provide an introduction to the available evidence base of actions to promote vaccine literacy. The research team organized interventions to create a tool that can inform health communicators and practitioners seeking a resource focused on strategy and implementation design for actions that support vaccine literacy. This scoping bibliography is honed specifically to respond to the urgency of the current pandemic, when supporting and increasing vaccine literacy offers promise for achieving the critically needed high levels of vaccination. Over the course of the coming months and year, this bibliography will be a dynamic and "living" document hosted and maintained on vaccineliteracy.com.

Behavioral Differences in the Preference for Hepatitis B Virus Vaccination: A Discrete Choice Experiment

Understanding behavioral factors differences in the preferences for vaccinations can improve predictions of vaccine uptake rates and identify effective policy interventions to increase the demand for vaccinations. In this study, 353 adults in Shandong province in China were interviewed about their preferences for hepatitis B virus (HBV) vaccination. A discrete choice experiment (DCE) was employed to analyze the preference for HBV vaccinations, and a mixed logit model was used to estimate respondent preferences for vaccination attributes included in the DCE. While the protection rate against hepatitis B (HB), duration of protection, risk of side-effects, and vaccination cost were shown to influence adults’ preferences for HBV vaccination, adults valued “99% hepatitis B protection” above other attributes, followed by “20 years’ protection duration” and “1 in 150,000 risk of side-effects”. Individuals with lower time discount rates, non-overconfidence, or higher risk aversion were more likely to choose a vaccine. Lower risk aversion individuals showed a higher preference for lower risk of side-effects. Lower time discount rate individuals showed a higher preference for longer protection duration. Non-overconfidence individuals showed a higher preference for higher hepatitis B protection and cost. Interventions should be targeted to the behavioral determinants impeding vaccination.

Parent Preferences for Pediatric Clinician Messaging to Promote Smoking Cessation Treatment

BACKGROUND AND OBJECTIVES

Insights from behavioral economics suggests that the effectiveness of health messages depends on how a message is framed. Parent preferences for smoking cessation messaging has not been studied in pediatrics, warranting further exploration to maximize benefit. We sought to assess parents' perceptions regarding the relative importance of distinct message framings to promote their smoking cessation.

METHODS

We conducted a cross-sectional discrete choice experiment in which parent smokers rated the relative importance of 26 messages designed to encourage them to begin cessation treatment. Messages varied on who was featured (child, parent, or family), whether the message was gain or loss framed, and what outcome was included (general health, cancer, respiratory illnesses, child becoming a smoker, or financial impact). The participants were 180 parent smokers attending primary care visits with their children at 4 diverse pediatric sites. The main outcome was the importance of smoking cessation messages based on who was featured, gain or loss framing, and the outcome emphasized.

RESULTS

Parent smokers highly prioritized cessation messages emphasizing the impact of quitting smoking on their child versus parent or family. Messages focusing on respiratory illness, cancer, or general health outcomes consistently ranked highest, whereas messages focused on the financial benefits of quitting ranked lowest. Gain versus loss framing did not meaningfully influence rankings.

CONCLUSIONS

Parent smokers identified smoking cessation messages that emphasized the impact on their child, with outcomes focused on respiratory health, cancer, or general health, as most important. The clinical impact of these messages should be tested in future research.

The Myth of Mycotoxins and Mold Injury

In recent years, mold has been blamed for many symptoms or a constellation of symptoms. These symptoms are usually vague and subjective and difficult or impossible to measure or quantify. Moreover, there is no scientific evidence that mold has anything to do with these symptoms. In particular, the concept of toxic mold syndrome has permeated the public consciousness, and mycotoxins have falsely been associated with autoimmune diseases and a variety of other conditions. In fact, there is no evidence that the presence of mycotoxins in the air is enough to cause any disease known to man. Molds legitimately can cause allergies and can be a trigger for asthma. Certain specific molds such as Aspergillus can be a cause of hypersensitivity pneumonitis. In immunocompromised hosts, both dermatologic and systemic infections can result from various fungi and can be associated with significant morbidity or even mortality. However, the existence of toxic mold syndrome has been disproven, despite the numerous disreputable practices such as testing homes for mold spores, measuring "mycotoxins" in the urine, and testing patients for IgG to mold. In truth, none of these techniques have been validated, nor do they have any relevance to any clinical disease. All that these tests that are being performed by laboratories of disrepute does is to further propagate misinformation and inflict unnecessary and often exorbitant costs on patients desperate for a clinical diagnosis, right or wrong, for their constellation of maladies.

A Values-Tailored Web-Based Intervention for New Mothers to Increase Infant Vaccine Uptake: Development and Qualitative Study

BACKGROUND

Vaccine hesitancy among parents leads to childhood undervaccination and outbreaks of vaccine-preventable disease. As the reasons for vaccine hesitancy are diverse, there is often not enough time during regular clinical visits for medical providers to adequately address all the concerns that parents have. Providing individually tailored vaccine information via the internet before a clinical visit may be a good mechanism for effectively allaying parents' vaccination concerns while also being time efficient. Including tailoring based on values is a promising, but untested, approach to message creation.

OBJECTIVE

This study aimed to describe the process by which we developed a Web-based intervention that is being used in an ongoing randomized controlled trial aimed at improving the timeliness of infant vaccination by reducing parental vaccine hesitancy.

METHODS

Development of the intervention incorporated evidence-based health behavior theories. A series of interviews, surveys, and feedback sessions were used to iteratively develop the intervention in collaboration with vaccination experts and potential end users.

RESULTS

In all, 41 specific content areas were identified to be included in the intervention. User feedback elucidated preferences for specific design elements to be incorporated throughout the website. The tile-based architecture chosen for the website was perceived as easy to use. Creating messages that were two-sided was generally preferred over other message formats. Quantitative surveys identified associations between specific vaccine values and vaccination beliefs, suggesting that values tailoring should vary, depending on the specific belief being endorsed.

CONCLUSIONS

Using health behavior theories, qualitative and quantitative data, and significant expert and end user input, we created a novel, Web-based intervention to improve infant vaccination timeliness. The intervention is based on tailoring messages according to each individual's values and beliefs. This intervention is currently being tested in a controlled randomized clinical trial.

An assessment of parental knowledge, attitudes, and beliefs regarding influenza vaccination

INTRODUCTION

Seasonal influenza imposes a significant clinical and economic burden. Despite the availability of an annual vaccine to prevent influenza infection and reduce disease severity, influenza vaccination rates remain suboptimal. Research suggests personal experience, perceived effectiveness, and concerns regarding vaccine safety and side effects are the most influential factors in predicting a parent's decision to vaccinate. However, current literature is primarily focused on the vaccine decision-making of healthcare workers and those at high risk for influenza complications.

METHODS

To assess parental attitudes and beliefs regarding the influenza vaccine, a brief mixed-methods survey was developed and optimized for an electronic platform. The Health Belief Model informed survey design and data analysis. Questions were classified into five core concepts: knowledge, barriers, benefits, experience, and severity. Participants were solicited from a population of parents whose children had participated in a school-based influenza surveillance study (n = 244, 73% response rate). We tested associations between responses and children's influenza vaccination status the prior season. Categorical questions were tested using Pearson's chi-squared tests and numerical or ordered questions using Mann-Whitney tests. P-values were corrected using the Bonferroni method.

RESULTS

Doubting effectiveness, concerns about side effects, inconvenience, and believing the vaccine is unnecessary were barriers negatively associated with parents' decision to vaccinate their children during the 2017-18 flu season (p < 0.001). Knowledge that the vaccine is effective in lowering risk, duration, and severity of influenza; receiving the influenza vaccine as an adult; and recognizing the importance of vaccination to prevent influenza transmission in high-risk populations were positively associated with parents' decision to vaccinate (p < 0.001).

CONCLUSION

Understanding barriers and motivators behind parents' decision to vaccinate provides valuable insight that has the potential to shape vaccine messaging, recommendations, and policy. The motivation to vaccinate to prevent influenza transmission in high-risk populations is a novel finding that warrants further investigation.

Informed Consent to Vaccination: Theoretical, Legal, and Empirical Insights

Informed consent matters - so does protecting people from infectious diseases. This paper examines what the appropriate informed consent process for vaccines should look like and how the process is conceptualized by law and health authorities. Drawing on the extensive theoretical and empirical literature on informed consent and vaccination, this article sets out what an ideal informed consent process for vaccination would consist of, highlighting the need for autonomous decisions. To be autonomous, decisions need to be based on full, accessible information and reached without coercion. We suggest that the information provided must address the nature of the procedure - including benefits to the child, benefits to society, and risks. Parents should have their concerns and misconceptions addressed. The information needs to be accessible and include an opportunity to ask questions. Based on this ideal model we examined in detail the legal framework surrounding informed consent to vaccination and the process as conceptualized by health authorities in two countries, Israel and the United States, to assess whether they meet the requirements. These two countries are similar in some of their values, for example, the importance of individual autonomy, and face similar problems related to vaccine hesitancy. At the same time, there are meaningful differences in their vaccine policies and the current structures of their informed consent processes, allowing for a meaningful comparison. We found neither country met our ideal informed consent process, and suggested improvements both to the materials and to the processes used to obtain informed consent.

Understanding non-vaccinating parents' views to inform and improve clinical encounters: a qualitative study in an Australian community

OBJECTIVES

To explain vaccination refusal in a sample of Australian parents.

DESIGN

Qualitative design, purposive sampling in a defined population.

SETTING

A geographically bounded community of approximately 30 000 people in regional Australia with high prevalence of vaccination refusal.

PARTICIPANTS

Semi structured interviews with 32 non-vaccinating parents: 9 fathers, 22 mothers and 1 pregnant woman. Purposive sampling of parents who had decided to discontinue or decline all vaccinations for their children. Recruitment via local advertising then snowballing.

RESULTS

Thematic analysis focused on explaining decision-making pathways of parents who refuse vaccination. Common patterns in parents' accounts included: perceived deterioration in health in Western societies; a personal experience introducing doubt about vaccine safety; concerns regarding consent; varied encounters with health professionals (dismissive, hindering and helpful); a quest for 'the real truth'; reactance to system inflexibilities and ongoing risk assessment.

CONCLUSIONS

We suggest responses tailored to the perspectives of non-vaccinating parents to assist professionals in understanding and maintaining empathic clinical relationships with this important patient group.

Adult vaccination as part of a healthy lifestyle: moving from medical intervention to health promotion

As the global population ages, there is concern about the effect of an increased proportion of older individuals on the economic sustainability of healthcare systems and the social effects of an older society. Health authorities and advocacy groups in countries at the forefront of this trend are now developing strategies to ameliorate the social and financial effects of an ageing population. There is broad agreement that for both society and for the individuals, it is important to ensure that increasing lifespans are matched with increased "healthspans" - the number of years spent in good health. There is also growing consensus that vaccination is one of the tools that can play an important role in improving adult health - though currently vaccination coverage is often poor. This review focuses on two issues that consistently appear to be associated with under-vaccination: the low awareness of risk (and potential consequences) for vaccine-preventable diseases and a poor understanding of the value of improved vaccination coverage for adults. We suggest that understanding of vaccination as a health-promoting activity, rather than a medical intervention designed to prevent the spread of a specific pathogen - is a crucial step to improve vaccination uptake among adults (see Supplementary video abstract ). Key messages As populations age globally, we are seeing an increasing burden of vaccine-preventable disease in adults. Adult vaccination against some common diseases has been shown to dramatically improve health and quality of life for older people. Despite the attested benefits, vaccination coverage is almost always poor in adults, even in countries where access is free at point of care. In this article, we discuss what appears to a neglected issue in adult vaccination, that of personal autonomy. We argue that adult vaccination will only be successful if it respects individual autonomy and that this requires treating the choice to vaccinate as a public health issue akin to smoking cessation, exercise and healthy diet.

Influenza vaccination discourse in major Canadian news media, 2017-2018

Influenza vaccine uptake is less-than-ideal in many jurisdictions, including Canada. In this study we sought to assess news articles relating to influenza vaccination by major Canadian newspapers during a six-month period relatively congruent to the seasonal influenza outbreak for 2017-2018. We identified 116 unique articles published between August 16, 2017 and February 15, 2018, then developed and applied a coding frame to them. Influenza vaccination was portrayed primarily positively (74.14%), sometimes negatively (14.66%), and occasionally neutrally (11.21%). Articles were most commonly focused on news about the prevalence, or amount of harm/death caused by, the influenza virus (31.03%), or on public announcements primarily concerning influenza vaccination (17.24%). Benefits of influenza vaccination were often stated (59.48%), most commonly including reduction in disease (47.41%) and protection of vulnerable individuals (26.72%). Issues or problems with influenza vaccination were also often stated (55.17%), most commonly relating to low or non-effectiveness of the vaccine (43.10%). Most articles stated that people should get vaccinated (65.52%). Canadian newspaper articles generally support the scientific consensus that influenza vaccination is a highly positive intervention. Nonetheless, a clear picture of the true value of influenza vaccination may sometimes be missing in articles focusing on low effectiveness and lacking any mention of vaccination's positive value. Overall, we can reasonably conclude that, in Canada, misinformation and antivaccination rhetoric are coming primarily from sources other than newspapers.

Interventions to help people understand community immunity: A systematic review

BACKGROUND

Herd immunity, or community immunity, occurs when susceptible people in a population are indirectly protected from infection thanks to the pervasiveness of immunity within the population. In this study, we aimed to systematically review interventions designed to communicate what community immunity is and how community immunity works to members of the general public.

METHODS

We searched PubMed, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials and Web of Science for peer-reviewed articles describing interventions with or without evaluations. We then conducted web searches with Google to identify interventions lacking associated publications. We extracted data about the target population of the interventions, the interventions themselves (e.g., did they describe what community immunity is, and how it works), any effects of evaluated interventions, and synthesized data narratively.

RESULTS

We identified 32 interventions: 11 interventions described in peer-reviewed articles and 21 interventions without associated articles. Of the 32 interventions, 5 described what community immunity is, 6 described the mechanisms of how community immunity occurs and 21 described both. Fourteen of the 32 addressed infectious diseases in general while the other 13 addressed one or more specific diseases. Twelve of the 32 interventions used videos, 7 used interactive simulations and 6 used questionnaires. Ten of the 11 peer-reviewed articles described studies evaluating at least one effect of the interventions. Within these 10, 4/4 reported increased knowledge, 3/5 reported shifts of attitudes in favour of vaccination, 2/5 reported increased intentions to vaccinate. Of 3 studies evaluating interventions specifically about community immunity, 2 reported increased intentions to vaccinate.

CONCLUSIONS

A compelling benefit of vaccination exists at the population level in the form of community immunity. Identifying ways to optimally communicate about this benefit may be important, because some evidence suggests that effective communication about community immunity can increase vaccination intentions.

Measles in Children

Measles, which until recently had been a rare disease in the United States, is re-emerging in our communities due to a combination of increased global mobility and decreased vaccinations across the country. As providers, we need to reacquaint ourselves with this disease so that we may diagnose it as well as educate our patients on how to prevent it. With public resistance to vaccinations on the rise, it is also important to be prepared to answer questions about the measles vaccine, its efficacy, and its side effects. By being educated ourselves, we will be able to educate our communities and help keep illnesses like measles at bay. [Pediatr Ann. 2018;47(9):e340-e344.].

Message framing and counseling of parents on children's physical activity - an experimental study

How messages are framed (gain or loss frame) modulate the effect of health information on physical activity level in adults. The role of framing of health information messages to parents about their child's physical activity is unknown.

Adult participants (parents) were randomized to see a video that either emphasized the benefits of physical activity (gain frame) or the risks of physical inactivity (loss frame) in children. The primary outcome was the change in the reported level of physical activity for their children between baseline and two-week follow-up.

92 individuals participated in the study and we obtained follow-up data for 48 participants (20 gain frame and 28 loss frame). Using a generalized linear model, we found that the frame presented to parents significantly influenced the trajectory of their child's physical activity (p = 0.03), with the loss frame condition resulting in more favorable trajectory. Both the willingness to pay for organized physical activities and the perceived barriers to physical activity were similar between the two intervention groups.

The change in the reported level of activity of the child over a two-week period was significantly different whether parents were exposed to a loss frame or a gain frame video message.

Human papillomavirus vaccine acceptability and decision-making among adolescent boys and parents: A meta-ethnography of qualitative studies

OBJECTIVE

Genital warts and human papillomavirus (HPV)-associated cancers in men can be substantially reduced through HPV vaccination; yet, globally, HPV vaccine uptake among boys remains low. This meta-ethnography synthesizes qualitative studies to understand, in-depth, HPV vaccine acceptability and decision-making among adolescent boys and/or their parents.

METHODS

A systematic search identified qualitative studies examining HPV vaccines from the perspectives of boys and/or boys' parents. The Consolidated Criteria for Reporting Qualitative Research (COREQ) 32-item checklist was used to assess quality of reporting. Using meta-ethnographic techniques, we conducted a structured and iterative process of data analysis, coded original studies, and then developed descriptive and analytic themes to synthesize the findings.

RESULTS

Review of 15 eligible studies (n = 3362 parents, n = 39 boys) revealed multilevel factors that influence HPV vaccine acceptability and decision-making among adolescent boys and their parents: (1) individual, e.g., low HPV vaccine knowledge/awareness, (2) interpersonal, e.g., key relationships between parents, sons, and healthcare providers (HCP), (3) community/societal, e.g., parental duty to protect, and (4) systemic, e.g., HPV vaccine messaging. Parents generally accepted adolescent boys' sexuality and the need for vaccination, motivated by wanting to protect their sons from HPV and HPV-associated cancers, and valued HCP-initiated discussion and recommendation. Acceptability was mitigated by low awareness/knowledge of HPV vaccines and low perceived benefits for boys, lack of HCP-initiated discussion, out-of-pocket costs, multiple doses, stigma, and mixed messages about HPV.

CONCLUSIONS

Multilevel factors influence HPV vaccine acceptability and decision-making among parents and their adolescent sons. Providing clear and unambiguous messages about HPV vaccines-for whom (boys and girls), for what (genital warts and cancers in men), and when (before sexual debut)-through increased HCP-initiated discussion and targeted public health campaigns may support HPV vaccine uptake among boys. Future research should consistently disaggregate findings by sex of child and parent, and explore effective messaging tailored for boys and parents.

Examining the "why" of vaccine hesitancy

Comments on the original article by Hornsey and colleagues (see record 2018-03974-001) which present findings on a 24-nation survey of the underlying roots of vaccine hesitancy and antivaccination attitudes. Their findings provide a solid foundation on which to build the next generation of research into vaccine communication and ways to address vaccine hesitancy. Where do we go from here? Although the work of Hornsey et al. (2018) is a good first step, their primary outcome was vaccination attitudes. Future research is needed to evaluate these findings in the context of actual vaccine uptake. (PsycINFO Database Record

Increasing Vaccination: Putting Psychological Science Into Action

Vaccination is one of the great achievements of the 20th century, yet persistent public-health problems include inadequate, delayed, and unstable vaccination uptake. Psychology offers three general propositions for understanding and intervening to increase uptake where vaccines are available and affordable. The first proposition is that thoughts and feelings can motivate getting vaccinated. Hundreds of studies have shown that risk beliefs and anticipated regret about infectious disease correlate reliably with getting vaccinated; low confidence in vaccine effectiveness and concern about safety correlate reliably with not getting vaccinated. We were surprised to find that few randomized trials have successfully changed what people think and feel about vaccines, and those few that succeeded were minimally effective in increasing uptake. The second proposition is that social processes can motivate getting vaccinated. Substantial research has shown that social norms are associated with vaccination, but few interventions examined whether normative messages increase vaccination uptake. Many experimental studies have relied on hypothetical scenarios to demonstrate that altruism and free riding (i.e., taking advantage of the protection provided by others) can affect intended behavior, but few randomized trials have tested strategies to change social processes to increase vaccination uptake. The third proposition is that interventions can facilitate vaccination directly by leveraging, but not trying to change, what people think and feel. These interventions are by far the most plentiful and effective in the literature. To increase vaccine uptake, these interventions build on existing favorable intentions by facilitating action (through reminders, prompts, and primes) and reducing barriers (through logistics and healthy defaults); these interventions also shape behavior (through incentives, sanctions, and requirements). Although identification of principles for changing thoughts and feelings to motivate vaccination is a work in progress, psychological principles can now inform the design of systems and policies to directly facilitate action.

Message Framing in Vaccine Communication: A Systematic Review of Published Literature

Suboptimal vaccination rates are a significant problem in many countries today, in spite of improved access to vaccine services. As a result, there has been a recent expansion of research on how best to communicate about vaccines. The purpose of the present article is to provide an updated review of published, peer-reviewed empirical studies that examined the effectiveness of gain versus loss framing (i.e., goal framing) in the context of vaccine communication. To locate studies, we examined the reference list from the previous meta-analytic review (O'Keefe & Nan, 2012), and we conducted systematic searches across multiple databases. We included 34 studies in the qualitative synthesis. The relative effectiveness of goal-framed vaccine messages was often shown to depend on characteristics of the message recipient, perceived risk, or situational factors, yet most effects were inconsistent across studies, or simply limited by an insufficient number of studies. Methodological characteristics and variations are noted and discussed. The review points to several directions concerning moderators and mediators of framing effects where additional rigorous studies would be needed.

Addressing barriers to vaccine acceptance: an overview

Addressing the drivers of vaccine hesitancy and the barriers to vaccine acceptance is a complex but important task. While the percentage of hesitant does vary from country to country and in time few, if any, countries are ever free from this problem. Overcoming hesitancy requires detection, diagnosis and tailored intervention as there is no simple strategy that can address all of the barriers to vaccine acceptance. Immunization program managers and health care workers need to become adept at recognizing and tackling hesitancy in all of its incarnations if high levels of vaccine acceptance are to be achieved but must also actively support immunization acceptors in order to build and support vaccine acceptance resiliency. This paper presents evidence-informed strategies to achieve these goals.

To close the childhood immunization gap, we need a richer understanding of parents' decision-making

Vaccination is widely acknowledged as one of the most successful public health interventions globally and in most high-income countries childhood vaccination coverage rates are moderately high. Yet in many instances, immunisation rates remain below aspirational targets and have shown only modest progress toward those targets in recent years, despite concerted efforts to improve uptake. In part, coverage rates reflect individual parents' vaccination attitudes and decisions and, because vaccination decision-making is complex and context-specific, it remains challenging at individual and community levels to assist parents to make positive decisions. Consequently, in the search for opportunities to improve immunisation coverage, there has been a renewed research focus on parents' decision-making. This review provides an overview of the literature surrounding parents' vaccination decision-making, offering suggestions for where efforts to increase vaccination coverage should be targeted and identifying areas for further research.

Social mobilisation, consent and acceptability: a review of human papillomavirus vaccination procedures in low and middle-income countries

BACKGROUND

Social mobilisation during new vaccine introductions encourages acceptance, uptake and adherence to multi-dose schedules. Effective communication is considered especially important for human papillomavirus (HPV) vaccine, which targets girls of an often-novel age group. This study synthesised experiences and lessons learnt around social mobilisation, consent, and acceptability during 55 HPV vaccine demonstration projects and 8 national programmes in 37 low and middle-income countries (LMICs) between January 2007 and January 2015.

METHODS

A qualitative study design included: (i) a systematic review, in which 1,301 abstracts from five databases were screened and 41 publications included; (ii) soliciting 124 unpublished documents from governments and partner institutions; and (iii) conducting 27 key informant interviews. Data were extracted and analysed thematically. Additionally, first-dose coverage rates were categorised as above 90 %, 90-70 %, and below 70 %, and cross-tabulated with mobilisation timing, message content, materials and methods of delivery, and consent procedures.

RESULTS

All but one delivery experience achieved over 70 % first-dose coverage; 60 % achieved over 90 %. Key informants emphasized the benefits of starting social mobilisation early and actively addressing rumours as they emerged. Interactive communication with parents appeared to achieve higher first-dose coverage than non-interactive messaging. Written parental consent (i.e., opt-in), though frequently used, resulted in lower reported coverage than implied consent (i.e., opt-out). Protection against cervical cancer was the primary reason for vaccine acceptability, whereas fear of adverse effects, exposure to rumours, lack of project/programme awareness, and schoolgirl absenteeism were major reasons for non-vaccination.

CONCLUSIONS

Despite some challenges in obtaining parental consent and addressing rumours, experiences indicated effective social mobilisation and high HPV vaccine acceptability in LMICs. Social mobilisation, consent, and acceptability lessons were consistent across world regions and HPV vaccination projects/programmes. These can be used to guide HPV vaccination communication strategies without additional formative research.