Understanding the interplay of factors informing vaccination behavior in three Canadian provinces

Lessons from a school-based vaccination response following a Diphtheria outbreak in eThekwini district, SA

Diphtheria is a life-threatening respiratory tract infection that causes outbreaks in susceptible populations. Between April and May 2018, an outbreak of diphtheria occurred in the eThekwini district. A school-based outbreak vaccination response was initiated to target vulnerable children and adolescents.

Contribution

This study adds to the limited data describing a school-based vaccination in an outbreak response and highlights successes and challenges. School-based outbreak vaccination response can rapidly increase vaccine coverage; however, additional community engagement may be required in vaccine-hesitant populations.

"There's a little bit of mistrust": Red River Métis experiences of the H1N1 and COVID-19 pandemics

We examined the perspectives of the Red River Métis citizens in Manitoba, Canada, during the H1N1 and COVID-19 pandemics and how they interpreted the communication of government/health authorities' risk management decisions. For Indigenous populations, pandemic response strategies play out within the context of ongoing colonial relationships with government institutions characterized by significant distrust. A crucial difference between the two pandemics was that the Métis in Manitoba were prioritized for early vaccine access during H1N1 but not for COVID-19. Data collection involved 17 focus groups with Métis citizens following the H1N1 outbreak and 17 focus groups during the COVID-19 pandemic. Métis prioritization during H1N1 was met with some apprehension and fear that Indigenous Peoples were vaccine-safety test subjects before population-wide distribution occurred. By contrast, as one of Canada's three recognized Indigenous nations, the non-prioritization of the Métis during COVID-19 was viewed as an egregious sign of disrespect and indifference. Our research demonstrates that both reactions were situated within claims that the government does not care about the Métis, referencing past and ongoing colonial motivations. Government and health institutions must anticipate this overarching colonial context when making and communicating risk management decisions with Indigenous Peoples. In this vein, government authorities must work toward a praxis of decolonization in these relationships, including, for example, working in partnership with Indigenous nations to engage in collaborative risk mitigation and communication that meets the unique needs of Indigenous populations and limits the potential for less benign-though understandable-interpretations.

How does collectivism help deal with perceived vaccine artificiality? The case of COVID-19 vaccination intent in European young adults

Vaccine "unnaturalness" (artificiality) is one of the major anti-vaccine arguments raised in public debate. Therefore, health communication should rebut unnaturalness arguments and be cautious when emphasizing human intervention (e.g., advanced vaccine technology), which may entail perceiving vaccines as artificial. Understanding how the relationship between perceived vaccine artificiality and vaccination intent differs across social groups can help enforce the above health communication efforts by focusing them on specific audiences. The objective of the current paper is to assess the moderating role of a particular socio-cultural factor-vertical collectivism (reflecting the orientation on social hierarchy)-in the relationship between perceived vaccine artificiality and vaccination intent. It is proposed that vertical collectivism diminishes the negative effect of perceived vaccine artificiality. Two studies with European young adults measured COVID-19 vaccination intent and vertical collectivism. Study 1 (N = 418) was correlational, measuring perceived vaccine artificiality. The data were analyzed with a moderation model. Study 2 (N = 203) was experimental, manipulating perceived vaccine artificiality by human-intervention appeal (i.e., emphasizing human intervention in vaccine development and operation). The data were analyzed with moderation and moderated mediation models. Study 1 demonstrated that the effect of perceived vaccine artificiality on vaccination intent was less negative when the level of vertical collectivism was higher. In Study 2, with higher levels of vertical collectivism, the effect of human-intervention appeal on vaccination intent was less negative, and the indirect effect through perceived vaccine artificiality turned even positive. Those results contribute to the fields of perceived naturalness/artificiality, vaccination behavior, health communication, and cultural dimensions theory, providing empirical evidence that the negative effect of perceived vaccine artificiality on vaccination intent is diminished by vertical collectivism, as proposed. Health practitioners are guided on how to consider different levels of collectivism of their audiences while referring to vaccine artificiality in their communication. Specifically, it is suggested that rebutting "unnaturalness" anti-vaccine arguments should be focused on people low in vertical collectivism, and messages featuring human intervention (e.g., a vaccine's technological advancement) should be targeted at people high in vertical collectivism.

Prevalence and factors associated with pentavalent vaccination: a cross-sectional study in Southern China

BACKGROUND

Immunization is one of the most far-reaching and cost-effective strategies for promoting good health and saving lives. A complex immunization schedule, however, may be burdensome to parents and lead to reduced vaccine compliance and completion. Thus, it is critical to develop combination vaccines to reduce the number of injections and simplify the immunization schedule. This study aimed to investigate the current status of the pentavalent diphtheria-tetanus-acellular pertussis inactivated poliomyelitis and Haemophilus influenzae type B conjugate (DTaP-IPV/Hib) vaccination in Southern China as well as explore the factors in the general population associated with uptake and the differences between urban and rural populations.

METHODS

A cross-sectional study was conducted with recently enrolled kindergarten students in Hainan Province between December 2022 and January 2023. The study employed a stratified multistage cluster random sampling method. Information regarding the demographic characteristics and factors that influence decisions were collected from the caregivers of children via an online questionnaire. Multivariate logistic regression was used to determine the factors associated with the status of DTap-IPV/Hib vaccinations.

RESULTS

Of the 4818 valid responses, 95.3% of children were aged 3-4 years, and 2856 (59.3%) held rural hukou. Coverage rates of the DTaP-IPV/Hib vaccine, from 1 to 4 doses, were 24.4%, 20.7%, 18.5%, and 16.0%, respectively. Caregivers who are concerned about vaccine efficacy [adjusted odds ratio (aOR) = 1.53, 95% confidence interval (CI): 1.30-1.79], the manufacturer (aOR = 2.05, 95% CI: 1.69-2.49), and a simple immunization schedule (aOR = 1.26, 95% CI: 1.04-1.54) are factors associated with a higher likelihood of vaccinating children against DTaP-IPV/Hib. In addition, caregivers in urban areas showed more concern about the vaccine price (P = 0.010) and immunization schedule (P = 0.022) in regard to vaccinating children.

CONCLUSIONS

The DTaP-IPV/Hib vaccine coverage rate in Hainan Province remains low. Factors such as lower socioeconomic status, cultural beliefs, concerns about vaccine safety, and cost may hinder caregivers from vaccinating their children. Further measures, such as health education campaigns to raise knowledge and awareness, and encouragement of domestic vaccine innovation, which would reduce out-of-pocket costs, could be implemented to improve the coverage of DTap-IPV/Hib vaccination.

The impact of collective action dilemma on vaccine hesitancy: Evidence from China

Vaccine hesitancy has dramatically decreased the speed of vaccination and stalled global health development. While the factors influencing vaccine hesitancy and mitigation measures have been explored in depth by existing studies, research from the perspective of human interaction is lacking. Based on the theory of collective action, this paper analyzes how free riding behavior affects vaccine hesitancy and how the vaccine hesitancy caused by free riding behavior can be solved. Using 2,203 survey data sets from China, this paper examines the influence of the collective action dilemma - represented by free riding behavior - on COVID-19 vaccine hesitancy. The empirical results show that the existence of free riding behavior is an essential cause of vaccine hesitancy. Based on this conclusion, this paper discusses how to further alleviate the problem of vaccine hesitancy caused by collective action dilemmas by promoting cooperation. The findings of this paper may be helpful to promote various types of vaccines and further suggest that countries should assume the perspective of solving the collective action dilemma to achieve increased vaccination rates.

"We need to protect each other": COVID-19 vaccination intentions and concerns among Racialized minority and Indigenous Peoples in Canada

People may choose to receive vaccines in response to pressures that outweigh any concerns that they have. We explored Racialized minority and Indigenous Peoples' motivations for, perceptions of choice in, and concerns about, COVID-19 vaccination. We used a sequential explanatory mixed methods approach, including a national survey administered around the time vaccines were first authorized (Dec 2020) followed by qualitative interviews when vaccines were becoming more readily available to adults (May-June 2021). We analyzed survey data using descriptive statistics and interviews using critical feminist methodologies. Survey respondents self-identified as a Racialized minority (n = 1488) or Indigenous (n = 342), of which 71.4% and 64.6%, respectively, intended to receive a COVID-19 vaccine. Quantitative results indicated perceptions of COVID-19 disease were associated with vaccination intention. For instance, intention was associated with agreement that COVID-19 disease is severe, risk of becoming sick is great, COVID-19 vaccination is necessary, and vaccines available in Canada will be safe (p < 0.001). COVID-19 vaccines were in short supply in Canada when we subsequently completed qualitative interviews with a subset of Racialized minority (n = 17) and Indigenous (n = 10) survey respondents. We coded interview transcripts around three emergent themes relating to governmentality and cultural approaches to intersectional risk theories: feelings of collective responsibility, choice as privilege, and remaining uncertainties about COVID-19 vaccines. For example, some mentioned the responsibility and privilege to receive a vaccine earlier than those living outside of Canada. Some felt constraints on their freedom to choose to receive or refuse a vaccine from intersecting oppressions or their health status. Although all participants intended to get vaccinated, many mentioned uncertainties about the safety and effectiveness of COVID-19 vaccination. Survey respondents and interview participants demonstrated nuanced associations of vaccine acceptance and hesitancy shaped by perspectives of vaccine-related risks, symbolic associations of vaccines with hope, and intersecting social privileges and inequities (including racialization).

Barriers to adult vaccination in Canada: A qualitative systematic review

Background:

In recent years, Canadian health care professionals have observed an increase in vaccine refusal. The objective of this study is to review published literature and identify the main themes related to vaccine hesitancy and barriers to vaccination in Canadian adults and recent immigrants.

Methods:

A qualitative systematic review was performed. A comprehensive search of MEDLINE (1946 to January 2021) and EMBASE (1974 to January 2021) was conducted to identify existing literature that addressed the primary research question. Studies were eligible for inclusion if the study population involved 1) the general population, 2) Indigenous populations, 3) recent immigrants to Canada or 4) Canadian health care professionals.

Results:

Thirty-four studies were included with a focus on the general population (n = 22), health care professionals (n = 10) and recent immigrant populations (n = 2). The most frequently reported barriers were lack of vaccine information (41%), lack of access to vaccination (38%), fear of adverse reactions (38%), financial reasons (29%), lack of awareness of vaccine existence (29%), antivaccine sentiments (24%), notion that older adults do not need vaccination (18%), misconceptions on vaccine effectiveness (12%), potential sexual health promotion stigma (6%) and fear of needles (3%).

Interpretation:

Barriers to vaccination among Canadians and recent immigrants continue to be a challenge in the health care system.

Conclusions:

The greatest yield in improving vaccination rates is likely to come from supporting vaccine-hesitant individuals in shifting their thinking to greater vaccine acceptance. Pharmacists are well positioned to address vaccine hesitancy and involvement through education, facilitation and administration of vaccines. Can Pharm J (Ott) 2022;155:xx-xx.

Do Optimists Like Vaccines? The Effect of Perceived Vaccine Novelty and Beliefs in the World’s Positivity and Orderliness on the Attitudes toward COVID-19 Vaccinations—The Case of European Young Adults

The public debate over COVID-19 vaccinations tends to focus on vaccine-related arguments, such as their effectiveness and safety. However, the characteristics of a person’s worldview, such as beliefs about the world’s positivity and orderliness, may also shape attitudes toward COVID-19 vaccinations. These relationships were investigated using schema incongruity theory. The degree of the vaccine’s incongruence with the world’s order schema existing in people’s minds was represented by perceived vaccine novelty. Accordingly, the results of an online survey among European young adults (N = 435) indicate that perceived vaccine novelty negatively affects behavioral outcomes (vaccination intent, willingness to pay for vaccinations, and vaccination advocacy). Moreover, there occurred a negative interaction effect of positivity and orderliness beliefs on behavioral outcomes. Specifically, an effect of positivity was more positive when people perceived the world as less ordered. Furthermore, this interaction effect was more negative when perceived vaccine novelty was higher. A mediating role of perceived vaccine effectiveness was demonstrated for the above relationships. The results extend the existing literature on people’s worldviews into the domain of vaccine attitudes, and provide new insights on the role of perceived vaccine novelty. For vaccination policymakers and marketers, the paper suggests how to promote vaccinations with consideration of orderliness/positivity beliefs and vaccine novelty perception.

"Until I Know It's Safe for Me": The Role of Timing in COVID-19 Vaccine Decision-Making and Vaccine Hesitancy

Managing the COVID-19 pandemic-and other communicable diseases-involves broad societal uptake of vaccines. As has been demonstrated, however, vaccine uptake is often uneven and incomplete across populations. This is a substantial challenge that must be addressed by public health efforts. To this point, significant research has focused on demographic and attitudinal correlates with vaccine hesitancy to understand uptake patterns. In this study, however, we advance understandings of individual decision-making processes involved in vaccine uptake through a mixed-methods investigation of the role of timing in COVID-19 vaccine choices. In the first step, a survey experiment, we find the timing of vaccine rollout (i.e., when a vaccine becomes available to the respondent) has a significant impact on public decision-making. Not only is there a higher level of acceptance when the vaccine becomes available at a later time, but delayed availability is correlated with both lower levels of 'desire to wait' and 'total rejection' of the vaccine. In a second step, we explore associated qualitative data, finding that temporal expressions (i.e., professing a desire to wait) can serve as a proxy for underlying non-temporal rationales, like concerns around safety, efficacy, personal situations, or altruism. By identifying these patterns, as well as the complexities of underlying factors, through a mixed-methods investigation, we can inform better vaccine-related policy and public messaging, as well as enhance our understanding of how individuals make decisions about vaccines in the context of COVID-19.

HPV vaccine: uptake and understanding among global Indigenous communities - a qualitative systematic review

BACKGROUND

Indigenous populations have a high prevalence of Human Papillomavirus (HPV) infection and a high incidence of HPV associated cancers, such as cervical and oropharyngeal cancer. There is an effective HPV vaccination program in almost all developed countries to prevent the incidence of cervical cancer, but reports suggest that the uptake of these vaccinations by Indigenous populations is low. The objective of this qualitative systematic review was to explore the knowledge and beliefs of global Indigenous populations regarding HPV vaccines. This review was performed to identify the barriers faced by Indigenous peoples and to provide evidence for more effective and acceptable execution of vaccination policies for Indigenous peoples.

METHODS

Two investigators independently searched MEDLINE, PubMed, SCOPUS, and Web of Science databases using a pre-specified search strategy to identify qualitative studies on narratives of Indigenous peoples regarding HPV vaccine awareness, knowledge and experiences across all geographic and income-level settings.

RESULTS

After performing the literature search and quality appraisals 5 papers were included in the final review. Three core synthesised findings were identified: reasons for acceptance or hesitancy, and areas for improvement. Lack of correct knowledge and mistrust in the healthcare system were important categories observed in all papers included in the review. Other categories within the conceptual model included prioritising disease prevention, health professional guidance, family support and supportive community environment.

CONCLUSION

Qualitative systematic reviews are an excellent means of exploring the gaps in current healthcare practices. Indigenous healthcare research should be grounded in community experiences and feedback. This review provides insights into HPV vaccination understanding and acceptance amongst Indigenous populations, from which recommendations for increasing resonance of vaccination strategies with Indigenous communities can be formed.

Universal Predictors of Dental Students' Attitudes towards COVID-19 Vaccination: Machine Learning-Based Approach

BACKGROUND

young adults represent a critical target for mass-vaccination strategies of COVID-19 that aim to achieve herd immunity. Healthcare students, including dental students, are perceived as the upper echelon of health literacy; therefore, their health-related beliefs, attitudes and behaviors influence their peers and communities. The main aim of this study was to synthesize a data-driven model for the predictors of COVID-19 vaccine willingness among dental students.

METHODS

a secondary analysis of data extracted from a recently conducted multi-center and multi-national cross-sectional study of dental students' attitudes towards COVID-19 vaccination in 22 countries was carried out utilizing decision tree and regression analyses. Based on previous literature, a proposed conceptual model was developed and tested through a machine learning approach to elicit factors related to dental students' willingness to get the COVID-19 vaccine.

RESULTS

machine learning analysis suggested five important predictors of COVID-19 vaccination willingness among dental students globally, i.e., the economic level of the country where the student lives and studies, the individual's trust of the pharmaceutical industry, the individual's misconception of natural immunity, the individual's belief of vaccines risk-benefit-ratio, and the individual's attitudes toward novel vaccines.

CONCLUSIONS

according to the socio-ecological theory, the country's economic level was the only contextual predictor, while the rest were individual predictors. Future research is recommended to be designed in a longitudinal fashion to facilitate evaluating the proposed model. The interventions of controlling vaccine hesitancy among the youth population may benefit from improving their views of the risk-benefit ratio of COVID-19 vaccines. Moreover, healthcare students, including dental students, will likely benefit from increasing their awareness of immunization and infectious diseases through curricular amendments.

Facilitators and Barriers to Providing Vaccinations During Hospital Visits

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

What factors promote vaccine hesitancy or acceptance during pandemics? A systematic review and thematic analysis

Examine the factors that promote vaccine hesitancy or acceptance during pandemics, major epidemics and global outbreaks. A systematic review and thematic analysis of 28 studies on the Influenza A/H1N1 pandemic and the global spread of Ebola Virus Disease. We found seven major factors that promote vaccine hesitancy or acceptance: demographic factors influencing vaccination (ethnicity, age, sex, pregnancy, education, and employment), accessibility and cost, personal responsibility and risk perceptions, precautionary measures taken based on the decision to vaccinate, trust in health authorities and vaccines, the safety and efficacy of a new vaccine, and lack of information or vaccine misinformation. An understanding of participant experiences and perspectives toward vaccines from previous pandemics will greatly inform the development of strategies to address the present situation with the COVID-19 pandemic. We discuss the impact vaccine hesitancy might have for the introduction and effectiveness of a potential COVID-19 vaccine. In particular, we believe that skepticism toward vaccines can still exist when there are no vaccines available, which is contrary to contemporary conceptualizations of vaccine hesitancy. We recommend conducting further research assessing the relationship between the accessibility and cost of vaccines, and vaccine hesitancy.

Understanding misinformation infodemic during public health emergencies due to large-scale disease outbreaks: a rapid review

AIM

The coronavirus disease 2019 (COVID-19) has caused hundreds of thousands of deaths, impacted the flow of life and resulted in an immeasurable amount of socio-economic damage. However, not all of this damage is attributable to the disease itself; much of it has occurred due to the prevailing misinformation around COVID-19. This rapid integrative review will draw on knowledge from the literature about misinformation during previous abrupt large-scale infectious disease outbreaks to enable policymakers, governments and health institutions to proactively mitigate the spread and effect of misinformation.

SUBJECT AND METHODS

For this rapid integrative review, we systematically searched MEDLINE and Google Scholar and extracted the literature on misinformation during abrupt large-scale infectious disease outbreaks since 2000. We screened articles using predetermined inclusion criteria. We followed an updated methodology for integrated reviews and adjusted it for our rapid review approach.

RESULTS

We found widespread misinformation in all aspects of large-scale infectious disease outbreaks since 2000, including prevention, treatment, risk factor, transmission mode, complications and vaccines. Conspiracy theories also prevailed, particularly involving vaccines. Misinformation most frequently has been reported regarding Ebola, and women and youth are particularly vulnerable to misinformation. A lack of scientific knowledge by individuals and a lack of trust in the government increased the consumption of misinformation, which is disseminated quickly by the unregulated media, particularly social media.

CONCLUSION

This review identified the nature and pattern of misinformation during large-scale infectious disease outbreaks, which could potentially be used to address misinformation during the ongoing COVID-19 or any future pandemic.

'I don't think anybody explained to me how it works': qualitative study exploring vaccination and primary health service access and uptake amongst Polish and Romanian communities in England

OBJECTIVES

This study explored vaccination attitudes and behaviours among Polish and Romanian communities, and related access to primary healthcare services.

DESIGN

A qualitative study using in-depth semistructured interviews with Polish and Romanian community members (CMs) and healthcare workers (HCWs) involved in vaccination in areas with large Polish and Romanian communities. CMs discussed their vaccination attitudes and their experiences of accessing vaccinations in England. HCWs shared their experiences in vaccinating Polish and Romanian communities.

SETTING

Recruitment focused on three geographical areas in England with large Polish and Romanian populations (in London, Lincolnshire and Berkshire).

PARTICIPANTS

20 Polish and 10 Romanian CMs, and 20 HCWs. Most CMs were mothers or pregnant women and were recruited from London or Lincolnshire. HCWs included practice nurses, health visitors and school nurses recruited from the targeted geographical areas.

RESULTS

Although most CMs reported vaccinating according to the UK schedule, obstacles to vaccination were highlighted. CMs experienced difficulties navigating and trusting the English primary healthcare system, and challenges in accessing credible vaccination information in Polish and Romanian. CM vaccination expectations, largely built on knowledge and experiences from Poland and Romania, were often unmet. This was driven by differences in vaccination scheduling and service provision in England, such as nurses delivering vaccines instead of doctors. CMs reported lower acceptance of the influenza vaccine, largely due to perceptions around the importance and efficacy of this vaccine. HCWs reported challenges translating and understanding vaccination histories, overcoming verbal communication barriers and ensuring vaccination schedule completeness among families travelling between England and Poland or Romania.

CONCLUSIONS

This study identified vaccination uptake and delivery issues and recommendations for improvement. HCWs should discuss health service expectations, highlight differences in vaccination scheduling and delivery between countries, and promote greater understanding of the English primary healthcare system in order to encourage vaccination in these communities.

Screening and vaccination as determined by the Social Ecological Model and the Theory of Triadic Influence: a systematic review

BACKGROUND

Vaccination and screening are forms of primary and secondary prevention methods. These methods are recommended for controlling the spread of a vast number of diseases and conditions. To determine the most effective preventive methods to be used by a society, multi-level models have shown to be more effective than models that focus solely on individual level characteristics. The Social Ecological Model (SEM) and the Theory of Triadic Influence (TTI) are such models. The purpose of this systematic review was to identify main differences and similarities of SEM and TTI regarding screening and vaccination in order to prepare potentially successful prevention programs for practice.

METHODS

A systematic review was conducted. Separate literature searches were performed during January and February 2015 using Medline, Ovid, Proquest, PubMed, University of Antwerp Discovery Service and Web of Science, for articles that apply the SEM and TTI. A Data Extraction Form with mostly closed-end questions was developed to assist with data extraction. Aggregate descriptive statistics were utilized to summarize the general characteristics of the SEM and TTI as documented in the scientific literature.

RESULTS

A total of 290 potentially relevant articles referencing the SEM were found. As for the TTI, a total of 131 potentially relevant articles were found. After strict evaluation for inclusion and exclusion criteria, 40 SEM studies and 46 TTI studies were included in the systematic review.

CONCLUSIONS

The SEM and TTI are theoretical frameworks that share many theoretical concepts and are relevant for several types of health behaviors. However, they differ in the structure of the model, and in how the variables are thought to interact with each other, the TTI being a matrix while the SEM has a ring structure. The main difference consists of the division of the TTI into levels of causation (ultimate, distal and proximal) which are not considered within the levels of the SEM. It was further found that in the articles studied in this systematic review, both models are often considered effective, while the empirical basis of these (and other) conclusions reached by their authors is in many cases unclear or incompletely specified.

The swine flu vaccine, public attitudes, and researcher interpretations: a systematic review of qualitative research

BACKGROUND

During pandemics, health authorities may be uncertain about the spread and severity of the disease and the effectiveness and safety of available interventions. This was the case during the swine flu (H1N1) pandemic of 2009-2010, and governments were forced to make decisions despite these uncertainties. While many countries chose to implement wide scale vaccination programmes, few accomplished their vaccination goals. Many research studies aiming to explore barriers and facilitators to vaccine uptake have been conducted in the aftermath of the pandemic, including several qualitative studies.

AIMS

1. To explore public attitudes to the swine flu vaccine in different countries through a review of qualitative primary studies. 2. To describe and discuss the implications drawn by the primary study authors.

METHODS

Systematic review of qualitative research studies, using a broadly comparative cross case-study approach. Study quality was appraised using an adaptation of the Critical Appraisal Skills Programme (CASP) quality assessment tool.

RESULTS

The review indicates that the public had varying opinions about disease risk and prevalence and had concerns about vaccine safety. Most primary study authors concluded that participants were uninformed, and that more information about the disease and the vaccine would have led to an increase in vaccine uptake. We find these conclusions problematic. We suggest instead that people's questions and concerns were legitimate given the uncertainties of the situation at the time and the fact that the authorities did not have the necessary information to convince the public. Our quality assessment of the included studies points to a lack of reflexivity and a lack of information about study context. We suggest that these study weaknesses are tied to primary study authors' lack of acknowledgement of the uncertainties surrounding the disease and the vaccine.

CONCLUSION

While primary study authors suggest that authorities could increase vaccine uptake through increased information, we suggest instead that health authorities should be more transparent in their information and decision-making processes in future pandemic situations.

Factors influencing H1N1 vaccine behavior among Manitoba Metis in Canada: a qualitative study

Background

During the first wave of the H1N1 influenza pandemic in 2009, Aboriginal populations in Canada experienced disproportionate rates of infection, particularly in the province of Manitoba. To protect those thought to be most at-risk, health authorities in Manitoba listed all Aboriginal people, including Metis, among those able to receive priority access to the novel vaccine when it first became available. Currently, no studies exist that have investigated the attitudes, influences, and vaccine behaviors among Aboriginal communities in Canada. This paper is the first to systematically connect vaccine behavior with the attitudes and beliefs that influenced Metis study participants’ H1N1 vaccine decision-making.

Methods

Researchers held focus groups (n = 17) with Metis participants in urban, rural, and remote locations of Manitoba following the conclusion of the H1N1 pandemic. Participants were asked about their vaccination decisions and about the factors that influenced their decisions. Following data collection, responses were coded into the broad categories of a social-ecological model, nuanced by categories stemming from earlier research. Responses were then quantified to show the most influential factors in positively or negatively affecting the vaccine decision.

Results

Media reporting, the influence of peer groups, and prioritization all had positive and negative influential effects on decision making. Whether vaccinated or not, the most negatively influential factors cited by participants were a lack of knowledge about the vaccine and the pandemic as well as concerns about vaccine safety. Risk of contracting H1N1 influenza was the biggest factor in positively influencing a vaccine decision, which in many cases trumped any co-existing negative influencers.

Conclusions

Metis experiences of colonialism in Canada deeply affected their perceptions of the vaccine and pandemic, a context that health systems need to take into account when planning response activities in the future. Participants felt under-informed about most aspects of the vaccine and the pandemic, and many vaccine related misconceptions and fears existed. Recommendations include leveraging doctor-patient interactions as a site for sharing vaccine-related knowledge, as well as targeted, culturally-appropriate, and empowering public information strategies to supply reliable vaccine and pandemic information to potentially at-risk Aboriginal populations.