Coverage with Selected Vaccines and Exemption from School Vaccine Requirements Among Children in Kindergarten - United States, 2022-23 School Year

Parental Factors Associated With Measles-Mumps-Rubella Vaccination in US Children Younger Than 5 Years

Objectives. To determine the association between parental characteristics and MMR (measles-mumps- rubella) vaccination status of children in the United States. Methods. We conducted a cross-sectional study from July 2023 to April 2024 using a digital health survey via OutbreaksNearMe, weighted to target national population characteristics. We analyzed the responses of 19 892 parents of children younger than 5 years to examine the association between self-reported parental characteristics (i.e., sociodemographics, politics, COVID-19 vaccination status) and children's MMR vaccination rates using logistic regression. Results. Children of parents who received at least 1 dose of the COVID-19 vaccine had higher MMR vaccination rates (80.8%) than did children of unvaccinated parents (60.9%; odds ratio [OR] = 1.84; 95% confidence interval [CI] = 1.68, 2.00). We observed lower MMR vaccination rates among children of parents who identified as Republican versus Democratic (OR = 0.73; 95% CI = 0.64, 0.82), parents on Medicaid or Medicare versus private insurance (OR = 0.85; 95% CI = 0.76, 0.95), and minority (OR = 0.44) versus White (OR = 0.71) parents. We found higher MMR vaccination rates in the Northeast and Midwest United States. Conclusions. Early data indicate that parental sociodemographic characteristics and COVID-19 vaccine status are associated with children's MMR vaccine uptake, emphasizing the need for further investigations into multipronged public health interventions. (Am J Public Health. 2025;115(3):369-373. https://doi.org/10.2105/AJPH.2024.307912).

Pediatric Vaccine Hesitancy in the United States-The Growing Problem and Strategies for Management Including Motivational Interviewing

Vaccine hesitancy is a significant global issue and is recognized by the World Health Organization (WHO) as one of the most pressing threats to public health. Defined as the delay in acceptance or refusal of vaccines despite their availability, vaccine hesitancy undermines decades of progress in preventing vaccine-preventable diseases. The issue is complex, influenced by misinformation, distrust in healthcare systems, cultural beliefs, and access barriers. These challenges require innovative and empathetic solutions to increase vaccine acceptance. Addressing this growing epidemic requires a multifaceted approach, which involves broader strategies and policymaking and in addition, effective communication tools for clinicians. Motivational Interviewing (MI), a patient-centered communication technique, offers an effective strategy to address pediatric vaccine hesitancy by fostering trust, understanding, and informed decision-making. This review aims to explore the problem of pediatric vaccine hesitancy in the United States, examine its underlying factors, and highlight evidence-based strategies, including Motivational Interviewing, to address this growing concern in clinical and public health settings. It offers practical guidance for healthcare providers and pediatricians to tackle this growing problem effectively and emphasizes the need for a combined effort of communication, community outreach, education, and systemic policy to overcome vaccine hesitancy.

On-time childhood vaccination before and during the COVID-19 pandemic in seven communities: Findings from the New Vaccine Surveillance Network

BACKGROUND

The COVID-19 pandemic raised unprecedented challenges to vaccinating children. This multi-center study aimed to compare on-time vaccination of children before and during the COVID-19 pandemic and identify key factors associated with on-time vaccination.

METHODS

This study was conducted among children aged 0-6 years enrolled in the New Vaccine Surveillance Network at seven geographically diverse U.S. academic medical centers. Children with acute respiratory illness or acute gastroenteritis were enrolled from emergency department and inpatient settings; healthy control subjects were enrolled from primary care practices. Vaccination data were collected and verified from patient medical records, immunization information systems, and/or provider documentation. On-time vaccination according to Advisory Committee on Immunization Practices recommendations was compared between pre-pandemic (December 2018-February 2020) and pandemic (March 2020-August 2021) periods using bivariate and multivariable analyses, adjusting for key demographic, clinical, and study characteristics.

RESULTS

A total of 24,713 children were included in the analytic sample (non-Hispanic 73.4 %; White 51.0 %; publicly insured 69.0 %). On-time vaccination declined between the pre-pandemic (67.3 %) and pandemic (65.4 %) periods (Adjusted Odds Ratio 0.89, 95 % CI 0.84-0.95). The largest declines were observed among children who were < 12 months, male, Black, publicly insured, or whose mothers had a high school-equivalent education or less. The pandemic impact also varied by vaccine type and study site.

CONCLUSIONS

This multi-center study revealed a relatively modest overall reduction in on-time vaccination, which may reflect multilevel efforts to address pandemic-associated challenges. However, some patient subgroups and sites experienced greater reductions in on-time vaccination, highlighting the importance of tailoring interventions to increase equitable vaccine delivery, access, and acceptance across populations and communities.

Parent Perspectives on Nirsevimab for Their Newborn

BACKGROUND

In 2023, nirsevimab, a monoclonal antibody against respiratory syncytial virus (RSV), was approved in the United States to be given to infants to prevent bronchiolitis, a leading cause of pediatric hospitalizations. We sought to better understand how parents of otherwise healthy newborns would respond to this recommendation.

METHODS

We conducted semistructured interviews of purposefully sampled parents of newborns admitted to the well newborn unit between November 2023 and February 2024. Interviews were performed in a constant comparative manner until thematic sufficiency was reached using the Health Beliefs Model as a conceptual framework.

RESULTS

We conducted 28 interviews: 38% of participants planned to give nirsevimab to their newborn, 25% did not plan to, and 38% were unsure. Four major themes emerged: (1) Major knowledge gaps existed about RSV prophylaxis; (2) trust in pediatrician's recommendation and fear of RSV infection contributed to uptake; (3) parents deferring RSV prophylaxis were concerned about side effects, wanted more time to decide, felt the maternal RSV vaccine was sufficient, and trusted their own prevention measures; and (4) there was misinformation about nirsevimab among parents including a perception that nirsevimab is a new understudied vaccine with similarities to the COVID-19 vaccine. Application of the Health Beliefs Model highlighted actionable opportunities to positively influence decision making around perceived susceptibility and RSV disease severity, benefits, barriers, self-efficacy, and cues to action.

CONCLUSIONS

Increasing overall awareness of both nirsevimab and RSV in infants, starting conversations during pregnancy to combat misinformation, leveraging trusting relationships with pediatricians and prenatal clinicians can help with future uptake.

Perspectives of Parents, School Nurses, and Pediatricians on Vaccine Hesitancy in St Louis County, Missouri

OBJECTIVES

To gather perspectives on childhood vaccination and vaccine hesitancy, the Saint Louis County Department of Public Health (DPH) surveyed parents seeking nonmedical exemptions, conducted focus groups of school nurses, and interviewed pediatricians.

METHODS

We distributed exemption forms and voluntary questionnaires to parents in St Louis County who were seeking nonmedical exemptions for their school-aged children at any DPH clinic from August 2019 through December 2022. We conducted and recorded four 75- to 90-minute focus groups of 11 school nurses in groups of 2 or 3 nurses in September 2022. We conducted and recorded interviews of 8 pediatricians in March 2023. We calculated descriptive statistics, transcribed focus group discussions and interviews, and performed qualitative coding.

RESULTS

We collected 1871 exemption forms. The median age of children (n = 1854) was 6 years. Of the 10 vaccines included in the exemption list, the percentage of exclusions ranged from 91.2% for meningococcal conjugate to 88.7% for hepatitis A. We identified 4 themes in the focus groups: recent changes in vaccine compliance, hesitancy and barriers, services addressing hesitancy and barriers, and future requests for DPH. Analysis of pediatrician interviews revealed themes relating to vaccine information, community efforts, and physician decision-making.

CONCLUSIONS

This study highlights the need for a multidisciplinary approach to vaccine hesitancy in St Louis County. Future interventions need to focus on beliefs and behavioral change related to vaccines and not just the economics and accessibility of vaccines.

Review: Known, Emerging, and Remerging Pharyngitis Pathogens

Pharyngitis is an inflammatory condition of the pharynx and/or tonsils commonly seen in both children and adults. Viruses and bacteria represent the most common encountered etiologic agents-yeast/fungi and parasites are infrequently implicated. Some of these are predominantly observed in unique populations (eg, immunocompromised or unvaccinated individuals). This article (part 1 of 3) summarizes the impact of acute pharyngitis on the health care system and reviews the etiologic agents of acute pharyngitis, including both emerging and reemerging pathogens that health care providers should consider when evaluating their patients. Finally, it sets the stage for parts 2 and 3, which discuss the current and evolving state of diagnostic testing for acute pharyngitis.

Trends in Vaccination Coverage among Children Aged 2-6 Years in Tennessee Counties, 2017-2023

Background/Objectives: This study examines trends in county-level vaccination coverage before, during, and after the COVID-19 pandemic among children aged 2-3 and 4-6 years in Tennessee, with a focus on rurality; Methods: Data from the Tennessee Immunization Information System (January 2017 to September 2023) were analyzed for vaccination coverage in children in both age groups. The study categorized the COVID-19 pandemic into three periods: pre-pandemic (P1: January 2017 to December 2019), stay-at-home (P2: January 2020 to May 2021), and reopening (P3: June 2021 to September 2023). Vaccination trends were stratified by vaccine type, rurality, sex, race and ethnicity; Results: During P1, there were no significant changes in trends of vaccination coverage percentages in both rural and urban counties for both age groups. However, vaccination coverage declined significantly during P2 and P3 compared to P1 for most vaccines, except for influenza, which initially increased but later declined. Rural counties experienced a more pronounced decline compared to urban counties during P2 and P3 for both age groups. Within rural and urban counties, vaccination coverage was higher among white children compared to black children, and among non-Hispanic compared to Hispanic children. There were higher coverage percentages in age group 4-6 for all vaccines, except for influenza, compared to 2-3 year group; Conclusions: The COVID-19 pandemic has exacerbated disparities in childhood vaccination coverage, particularly in rural areas. These findings highlight the need for targeted public health interventions to address barriers to vaccination and ensure equitable access to vaccines for all children.

Back to school: Routine vaccines for children and adolescents

ABSTRACT

Preparing for the new school year is an exciting and busy time. An important task for parents and caregivers during the back-to-school season is to ensure that their child or adolescent is up to date with their vaccines. NPs play a vital role in guiding parents and caregivers through the vaccination process, thereby ensuring that school-aged children and adolescents' health requirements are met. This article provides NPs with resources to assist in making decisions about child and adolescent immunizations. It also explores effective communication strategies to convey the benefits of vaccination to parents and caregivers, equipping NPs with the necessary knowledge and tools to navigate vaccination complexities and advocate for the health and safety of school-aged children and adolescents.

What's going on with measles?

Measles is a highly transmissible systemic viral infection associated with substantial mortality primarily due to secondary infections. Measles induces lifelong immunity to reinfection but loss of immunity to other pathogens. An attenuated live virus vaccine is highly effective, but lapses in delivery have resulted in increasing cases worldwide. Although the primary cause of failure to control measles is failure to vaccinate, waning vaccine-induced immunity and the possible emergence of more virulent virus strains may also contribute.

Specialized Vaccine Care for Adverse Events Following Immunization and Impact on Vaccine Hesitancy in the Military Health System

INTRODUCTION

The World Health Organization identified vaccine hesitancy as one of the top 10 threats to global health. Vaccine hesitancy is defined as a delay in acceptance or refusal of vaccination despite the availability of vaccination services. Because vaccine safety concerns are important contributors to hesitancy, people who have experienced adverse events following immunization (AEFI) may be at especially high risk for subsequent vaccine hesitancy. The Defense Health Agency Immunization Healthcare Division (DHA IHD) provides specialized vaccine care to persons who have experienced AEFI. The impact of this specialized vaccine care on subsequent vaccine hesitancy has not been fully explored.

MATERIALS AND METHODS

A cohort of patients (n= 146) was identified among those who received consultative care from DHA IHD clinicians for AEFI concerns between April 2017 and September 2022. Analyses were restricted to non-uniformed beneficiaries of the Military Health System (MHS). Uniformed beneficiaries of the MHS were excluded from this analysis since vaccination mandates preclude the use of vaccine uptake as a measure of vaccine hesitancy. Outcomes were evaluated by reviewing MHS vaccination records after initial AEFI consultation through January 2023. Vaccine acceptance was considered the inverse of hesitancy, and was defined by: (a) receipt of any subsequent vaccination, (b) receipt of seasonal influenza vaccine, (c) receipt of subsequent doses of the AEFI-associated vaccine, if clinically recommended, and (d) receipt of COVID-19 vaccine.

RESULTS

A diverse group of patients with a wide range of AEFI concerns received specialized vaccine care from DHA IHD clinicians during this period. Among the cohort, 78% of patients received any subsequent vaccination, 55.2% received seasonal influenza vaccine, 57.8% received a subsequent dose of their AEFI-associated vaccine when the vaccine was clinically recommended, and 48.9% received COVID-19 vaccine. The proportion of patients who received influenza vaccine exceeded the reported rate of influenza vaccine uptake by the general population during this time period.

CONCLUSION

Specialized vaccine care after AEFI concerns was associated with relatively high acceptance of subsequent vaccinations. The experiences of DHA IHD clinicians, in providing specialized vaccine care to AEFI patients, may serve as a model for other organizations that are working to reduce vaccine hesitancy, even beyond the MHS.

Health and Economic Benefits of Routine Childhood Immunizations in the Era of the Vaccines for Children Program - United States, 1994-2023

Since 1994, the U.S. Vaccines for Children (VFC) program has covered the cost of vaccines for children whose families might not otherwise be able to afford vaccines. This report assessed and quantified the health benefits and economic impact of routine U.S. childhood immunizations among both VFC-eligible and non-VFC-eligible children born during 1994-2023. Diphtheria and tetanus toxoids and acellular pertussis vaccine; Haemophilus influenzae type b conjugate vaccine; oral and inactivated poliovirus vaccines; measles, mumps, and rubella vaccine; hepatitis B vaccine; varicella vaccine; pneumococcal conjugate vaccine; hepatitis A vaccine; and rotavirus vaccine were included. Averted illnesses and deaths and associated costs over the lifetimes of 30 annual cohorts of children born during 1994-2023 were estimated using established economic models. Net savings were calculated from the payer and societal perspectives. Among approximately 117 million children born during 1994-2023, routine childhood vaccinations will have prevented approximately 508 million lifetime cases of illness, 32 million hospitalizations, and 1,129,000 deaths, at a net savings of $540 billion in direct costs and $2.7 trillion in societal costs. From both payer and societal perspectives, routine childhood vaccinations among children born during 1994-2023 resulted in substantial cost savings. Childhood immunizations continue to provide substantial health and economic benefits, while promoting health equity.

"Do not inject our babies": a social listening analysis of public opinion about authorizing pediatric COVID-19 vaccines

Designing effective childhood vaccination counseling guidelines, public health campaigns, and school-entry mandates requires a nuanced understanding of the information ecology in which parents make vaccination decisions. However, evidence is lacking on how best to "catch the signal" about the public's attitudes, beliefs, and misperceptions. In this study, we characterize public sentiment and discourse about vaccinating children against SARS-CoV-2 with mRNA vaccines to identify prevalent concerns about the vaccine and to understand anti-vaccine rhetorical strategies. We applied computational topic modeling to 149 897 comments submitted to regulations.gov in October 2021 and February 2022 regarding the Food and Drug Administration's Vaccines and Related Biological Products Advisory Committee's emergency use authorization of the COVID-19 vaccines for children. We used a latent Dirichlet allocation topic modeling algorithm to generate topics and then used iterative thematic and discursive analysis to identify relevant domains, themes, and rhetorical strategies. Three domains emerged: (1) specific concerns about the COVID-19 vaccines; (2) foundational beliefs shaping vaccine attitudes; and (3) rhetorical strategies deployed in anti-vaccine arguments. Computational social listening approaches can contribute to misinformation surveillance and evidence-based guidelines for vaccine counseling and public health promotion campaigns.

A neutralizing antibody prevents postfusion transition of measles virus fusion protein

Measles virus (MeV) presents a public health threat that is escalating as vaccine coverage in the general population declines and as populations of immunocompromised individuals, who cannot be vaccinated, increase. There are no approved therapeutics for MeV. Neutralizing antibodies targeting viral fusion are one potential therapeutic approach but have not yet been structurally characterized or advanced to clinical use. We present cryo-electron microscopy (cryo-EM) structures of prefusion F alone [2.1-angstrom (Å) resolution], F complexed with a fusion-inhibitory peptide (2.3-Å resolution), F complexed with the neutralizing and protective monoclonal antibody (mAb) 77 (2.6-Å resolution), and an additional structure of postfusion F (2.7-Å resolution). In vitro assays and examination of additional EM classes show that mAb 77 binds prefusion F, arrests F in an intermediate state, and prevents transition to the postfusion conformation. These structures shed light on antibody-mediated neutralization that involves arrest of fusion proteins in an intermediate state.

Measles - United States, January 1, 2020-March 28, 2024

Measles is a highly infectious febrile rash illness and was declared eliminated in the United States in 2000. However, measles importations continue to occur, and U.S. measles elimination status was threatened in 2019 as the result of two prolonged outbreaks among undervaccinated communities in New York and New York City. To assess U.S. measles elimination status after the 2019 outbreaks and to provide context to understand more recent increases in measles cases, CDC analyzed epidemiologic and laboratory surveillance data and the performance of the U.S. measles surveillance system after these outbreaks. During January 1, 2020-March 28, 2024, CDC was notified of 338 confirmed measles cases; 97 (29%) of these cases occurred during the first quarter of 2024, representing a more than seventeenfold increase over the mean number of cases reported during the first quarter of 2020-2023. Among the 338 reported cases, the median patient age was 3 years (range = 0-64 years); 309 (91%) patients were unvaccinated or had unknown vaccination status, and 336 case investigations included information on ≥80% of critical surveillance indicators. During 2020-2023, the longest transmission chain lasted 63 days. As of the end of 2023, because of the absence of sustained measles virus transmission for 12 consecutive months in the presence of a well-performing surveillance system, U.S. measles elimination status was maintained. Risk for widespread U.S. measles transmission remains low because of high population immunity. However, because of the increase in cases during the first quarter of 2024, additional activities are needed to increase U.S. routine measles, mumps, and rubella vaccination coverage, especially among close-knit and undervaccinated communities. These activities include encouraging vaccination before international travel and rapidly investigating suspected measles cases.

Long COVID's Impact on Patients, Workers, & Society: A review

The incidence of long COVID in adult survivors of an acute SARS-CoV-2 infection is approximately 11%. Of those afflicted, 26% have difficulty with day-to-day activities. The majority of long COIVD cases occur after mild or asymptomatic acute infection. Children can spread SARS-CoV-2 infections and can also develop long-term neurological, endocrine (type I diabetes), and immunological sequelae. Immunological hypofunction is exemplified by the recent large outbreaks of respiratory syncytial virus and streptococcal infections. Neurological manifestations are associated with anatomical brain damage demonstrated on brain scans and autopsy studies. The prefrontal cortex is particularly susceptible. Common symptoms include brain fog, memory loss, executive dysfunction, and personality changes. The impact on society has been profound. Fewer than half of previously employed adults who develop long COVID are working full-time, and 42% of patients reported food insecurity and 20% reported difficulties paying rent. Vaccination not only helps prevent severe COVID-19, but numerous studies have found beneficial effects in preventing and mitigating long COVID. There is also evidence that vaccination after an acute infection can lessen the symptoms of long COVID. Physical and occupational therapy can also help patients regain function, but the approach must be "low and slow." Too much physical or mental activity can result in post-exertional malaise and set back the recovery process by days or weeks. The complexity of long COVID presentations coupled with rampant organized disinformation, have caused significant segments of the public to ignore sound public health advice. Further research is needed regarding treatment and effective public communication.

Lessons learned from COVID-19, H1N1, and routine vaccine pharmacovigilance in the United States: a path to a more robust vaccine safety program

INTRODUCTION

Vaccine pharmacovigilance is an essential component of vaccine safety programs. Vaccine pharmacovigilance refers to detecting uncommon adverse events following immunization (AEFI), determining whether they are due to the vaccine or are only a coincidence, and, for those AEFI considered related to vaccination, characterizing them further. When AEFI are due to vaccination, it is important to characterize the attributable risk and ascertain the biological mechanism causing the adverse reaction to inform efforts to prevent or mitigate the risk. A robust post-authorization safety system is necessary for vaccine decision-making, clinical recommendations, vaccine compensation, and vaccine communication and confidence.

AREAS COVERED

This paper describes the key characteristics of vaccine pharmacovigilance programs, reviews US vaccine pharmacovigilance for routine vaccination programs, COVID-19, and H1N1, and makes recommendations for improving future vaccine safety systems.

EXPERT OPINION

The key characteristics of vaccine pharmacovigilance programs include passive surveillance, active surveillance, clinical investigation and special studies, and causality assessment. Recent examples illustrate the strengths of US pharmacovigilance systems, including systems for passive and active surveillance, as well as areas for improvement, including study of pathogenesis, consistent funding, and leadership. We make recommendations that would, if implemented, further strengthen the vaccine safety system for future routine and pandemic immunizations.

National trends in patterns of under-vaccination in early childhood: National Immunization Survey-Child, United States, 2011-2021

BACKGROUND

The study's objective was to examine national trends in patterns of under-vaccination in the United States.

RESEARCH DESIGN AND METHODS

The National Immunization Survey-Child (NIS-Child) is an annual cross-sectional survey that collects provider-verified vaccination records from a large national probability sample of children. Records from the 2011-2021 NIS-Child were used to assess receipt of the combined 7-vaccine series by age 24 months. Based on prior work, patterns indicative of hesitancy included zero vaccines, not starting ≥1 series, and consistent vaccine-limiting. Patterns indicative of practical issues included starting all series but missing doses. Up-to-date (UTD) was defined as receiving all doses in the combined 7-vaccine series.

RESULTS

The study population comprised 127,257 children. Over the observation period, patterns indicative of hesitancy significantly decreased (p-trend < 0.0001), patterns indicative of practical issues significantly decreased (p-trend < 0.0001), and UTD significantly increased (p-trend < 0.0001). In 2021, the weighted percentage in each category was as follows: probable hesitancy 6.3% (95% confidence interval [CI] 5.4%, 7.2%), probable practical issues 26.0% (95% CI 24.4%, 27.6%), and UTD 67.7% (95% CI 66.0%, 69.4%).

CONCLUSION

Over an 11-year period, vaccination coverage in the United States for the combined 7-vaccine series has improved, with patterns suggestive of practical issues or hesitancy declining.

Modeling undetected poliovirus circulation following the 2022 outbreak in the United States

BACKGROUND

New York State (NYS) reported a polio case (June 2022) and outbreak of imported type 2 circulating vaccine-derived poliovirus (cVDPV2) (last positive wastewater detection in February 2023), for which uncertainty remains about potential ongoing undetected transmission.

RESEARCH DESIGN AND METHODS

Extending a prior deterministic model, we apply an established stochastic modeling approach to characterize the confidence about no circulation (CNC) of cVDPV2 as a function of time since the last detected signal of transmission (i.e. poliovirus positive acute flaccid myelitis case or wastewater sample).

RESULTS

With the surveillance coverage for the NYS population majority and its focus on outbreak counties, modeling suggests a high CNC (95%) within 3-10 months of the last positive surveillance signal, depending on surveillance sensitivity and population mixing patterns. Uncertainty about surveillance sensitivity implies longer durations required to achieve higher CNC.

CONCLUSIONS

In populations that maintain high overall immunization coverage with inactivated poliovirus vaccine (IPV), rare polio cases may occur in un(der)-vaccinated individuals. Modeling demonstrates the unlikeliness of type 2 outbreaks reestablishing endemic transmission or resulting in large absolute numbers of paralytic cases. Achieving and maintaining high immunization coverage with IPV remains the most effective measure to prevent outbreaks and shorten the duration of imported poliovirus transmission.

Using machine learning to identify COVID-19 vaccine-hesitancy predictors in the USA

Introduction

Vaccine hesitancy is complex, multicausative phenomenon that undermines public health efforts to contain the spread of infectious diseases. Improving our understanding of the drivers of vaccine hesitancy might improve our capacity to address it.

Methods

We used the results of the May 2021 Assistant Secretary for Planning and Evaluation's survey on COVID-19 vaccine hesitancy, which estimated the proportion of adults for every US county that felt either hesitant or unsure and strongly hesitant towards taking the COVID-19 vaccine when it becomes available. We developed a prediction model to identify the most important predictors of vaccine hesitancy. The potential predictors included demographic characteristics, the Centers for Disease Control and Prevention's Social Vulnerability Index and the Republican Party's voting share in the 2020 presidential election as a proxy of political affiliation, all at the county level.

Results

We found that the main drivers of vaccine hesitancy are income level, marital status, poverty, income, schooling, race/ethnicity, age, health insurance status and political affiliation. While the drivers are shared by both levels of hesitancy, the order changes. Particularly, political affiliation is a more important predictor for strong hesitancy than for hesitancy or unsure.

Conclusions

These results deepen our understanding of the phenomenon and could help design more targeted interventions to reduce hesitancy in specific subgroups of the population.