Vaccination coverage during pregnancy and factors associated with refusal of recommended vaccinations: An Italian cross sectional study

Background

The vaccines recommended during pregnancy are the Tdap, the influenza vaccine, and, during the SARS-CoV-2 pandemic, the vaccine against COVID-19. This survey aimed at determining vaccination coverage among pregnant women and adverse events, reasons for vaccine refusal, and factors associated with vaccine uptake.

Methods

A single-center cross-sectional study was conducted on women who delivered between March and April 2022 at Careggi University Hospital in Florence, Italy. Information on the vaccinations (Tdap, influenza and COVID-19) received during pregnancy were collected through in-person interviews.

Results

Among 307 enrolled women (response rate 99 % on a study population of 310 eligible women), 74 % of patients were vaccinated with Tdap, 82 % against COVID-19, and only 33 % against influenza. Vaccination coverage for Tdap and COVID-19 was significantly higher among Italian than foreign patients (80 % vs 51 %, p < 0.001 and 86 % vs 69 %, p = 0.002, respectively), and for Tdap was higher among patients followed in the private vs public care setting. The main reasons behind refusal of vaccinations were low risk perception of influenza (41 %), insufficient information received from the prenatal care provider regarding the Tdap (35 %), and, for the COVID-19, fear of vaccine side effects (64 %), and concerns about effects on the fetus (70 %).

Conclusions

Adherence to the influenza vaccine was low because of reduced perception of the disease risks. The difference in vaccination coverage between Italians and foreigners is an example of healthcare disparity. Better information provided to patients about vaccines' efficacy and safety is advisable to increase acceptance of recommended vaccines.

Understanding factors associated with COVID-19 vaccination among health care workers using the Diffusion of Innovation Theory

BACKGROUND

The COVID-19 vaccine was initially offered to frontline health care workers (HCWs), due to the high risk of contracting COVID-19 through occupational exposure to patients. Low HCW vaccine uptake can impact overall community-level vaccine uptake. This study used the Diffusion of Innovation (DOI) Theory to understand factors related to COVID-19 vaccine uptake in HCWs.

METHODS

We surveyed Pennsylvanian HCWs (excluding Philadelphia) from August 2022 to February 2023. Survey questions inquired about demographics, COVID-19 vaccination status, reasons for receiving/declining the COVID-19 vaccine, and sources of information about the vaccine.

RESULTS

Participants (n = 3,490) were 85% female, 89% White, and 93% (n = 3,255) reported receiving at least one dose of a COVID-19 vaccine. HCWs were categorized into adopter categories of the DOI Theory: innovators (56%), early adopters (9%), early majority (11%), late majority (7%), and laggards (17%). The major reason that prompted participants to get the vaccine was to protect them against COVID-19 infection (78%), while the major reason for declining the vaccine was due to concern about possible side effects from the vaccine (78%).

CONCLUSIONS

We applied the DOI Theory to characterize adopters and identify factors related to COVID-19 vaccine uptake in HCWs. As updated COVID-19 vaccines are approved for the United States market, our findings may be used to improve vaccine education and communication among HCWs to support vaccine uptake.

Experiences of Malaysian primary healthcare providers with vaccine hesitancy: A qualitative study

Introduction

Vaccine hesitancy was declared as one of the ten threats to global public health by the World Health Organization in 2019. It undermines the effort towards eradication of vaccine-preventable diseases. Healthcare providers, who are directly involved in vaccination services and vaccine advocacies, are important in combating vaccine hesitancy. Studies have shown that vaccine refusers have various reasons for refusal including distrust towards healthcare providers. Hence, it is important to understand healthcare providers' perspectives. This study aimed to explore primary healthcare providers (PHCPs)' experiences in dealing with vaccine hesitancy.

Methods

This qualitative study was conducted among public PHCPs across six states in Malaysia. Purposive and snowball sampling methods were used. Fifteen primary healthcare doctors and nurses underwent in-depth interviews. Recruitment was stopped when data saturation was achieved. Data were thematically analysed.

Results

Four themes emerged: 1) views towards vaccination and vaccine hesitancy, 2) disparity in strategies and resources used among PHCPs, 3) fixed-minded vaccine deniers and religious incompatibility: the two towering hurdles and 4) negative impact after encounters with vaccine hesitancy.

Conclusion

Malaysian PHCPs encounter negative experiences with vaccine hesitancy, impacting them negatively. These experiences are attributed to the challenges and lack of standardised resources for reference. These findings suggest the development of a more flexible policy, a training module inclusive of all professional roles and a standardised repository of resources for managing vaccine hesitancy.

Identifying trusted local sources and predicting behavior change pathways according to COVID-19 vaccination status: Results of a 2022 statewide survey of Alaskan adults

BACKGROUND

Low rates of COVID-19 vaccination remain a substantial public health challenge. Despite early successes, vaccinations of Alaskans trail the US average, drawing attention to the need for better-designed and targeted vaccine confidence interventions. Our objective was to assess levels of community trust and theory-driven predictors of vaccination status to inform the design of future programs.

METHODS

We conducted a cross-sectional, telephone-based survey of 940 Alaskan adults between May and June 2022. Data were collected on vaccination status (including initial vaccination and receipt of booster shots), trust in local community members, demographic characteristics, and thematic questions designed using the Capability, Opportunity, Motivation - Behavior (COM-B) model to examine possible predictors (barriers/facilitators) of vaccination status.

FINDINGS

Among those who are not fully vaccinated and boosted, we observe significantly lower trust placed in many immediate community members, especially health workers (e.g., doctors, nurses, specialty care physicians, health administrators). Firefighters and emergency medical technicians enjoy the most community trust, followed by medical professionals. Among those who received only a primary vaccine series, we find that perceptions of whether close friends are vaccinated, a sense of professional responsibility, and age were the strongest predictors vaccination status. Among the unvaccinated, we find significant predictive power from the same variables, as well as perceptions of whether family members are vaccinated, perceived risks from non-vaccination and whether vaccination is a healthy choice.

CONCLUSIONS

These findings will help inform the design and targeting of future vaccine promotion interventions to adult populations in Alaska. Interventions that leverage reflective motivation and social opportunity domains of the COM-B framework may be most effective. Local community members including firefighters and emergency medical technicians, as well as medical professionals may be perceived as the most trustworthy and influential messengers among those who are not fully vaccinated and boosted.

Characterizing predictors of COVID-19 vaccine refusal in an urban southern California jail population

BACKGROUND

Correctional populations have been disproportionately affected by COVID-19, and many large outbreaks have occurred in jails and prisons. Vaccination is a key strategy to reduce the SARS-CoV-2 transmission in carceral settings. Although implementation can be challenging due to vaccine hesitancy and medical mistrust, correctional settings provide largely equitable healthcare access and present a unique opportunity to identify potential predictors of vaccine hesitancy independent of access issues.

METHODS

We retrospectively analyzed electronic health record data for individuals offered COVID-19 vaccination at the Los Angeles County Jail between January 19, 2021, and January 31, 2023, and used multivariable logistic regression to determine predictors of COVID-19 vaccine refusal.

RESULTS

Of the 21,424 individuals offered COVID-19 vaccination, 2,060 (9.6 %) refused. Refusal was associated with male sex ([aOR] = 2.3, 95 % CI (1.9, 2.8)), age 18-34 ([aOR] = 1.2, 95 % CI (1.1, 1.4), referent group: age 45-54), Black race ([aOR] = 1.2, 95 % CI (1.1, 1.4)), reporting ever being houseless ([aOR] = 1.2, 95 % CI (1.1, 1.3)), and having a history of not receiving influenza vaccination while incarcerated ([aOR] = 2.4, 95 % CI (2.0, 2.8)). When analyzing male and female populations separately, male-specific trends reflected those seen in the overall population, whereas the only significant predictor of vaccine refusal in the female population was not receiving influenza vaccination while in custody ([aOR] = 6.5, 95 % CI (2.4, 17.6)).

CONCLUSION

Identifying predictors of vaccine refusal in correctional populations is an essential first step in the development and implementation of targeted interventions to mitigate vaccine hesitancy.

Hesitancy or Resistance? Differential Changes in COVID-19 Vaccination Intention Between Black and White Americans

The literature on COVID-19 vaccination has rarely taken a macro and longitudinal approach to investigate the nuanced racial and ethnic differences in vaccine hesitancy and refusal. To fill this gap, this study examines the relationships between race, time, and COVID-19 vaccine hesitancy and refusal using state-level data from the US Census Household Pulse Survey, 2020 US Decennial Census, and other sources (i.e., American Community Survey, Human Development Index database, and Centers for Disease Control and Prevention). Four longitudinal Generalized Estimating Equations (GEEs) were estimated to analyze how time-variant and time-invariant measures, and time itself influenced COVID-19 vaccine hesitancy and refusal rates, controlling for the effect of other relevant covariates. The results provide descriptive evidence that COVID-19 vaccine hesitancy had decreased in the USA, but vaccine refusal remained stable between January and October 2021. The GEEs further indicated that the proportion of the Black population was positively associated with both vaccine hesitancy and refusal rates, while the proportion of the White population was positively associated with the vaccine refusal rate but not associated with the vaccine hesitancy rate. In addition, over the 10-month period, COVID-19 vaccine hesitancy and refusal in the Black population declined rapidly, but vaccine refusal in the White population stayed fairly stable. More research and practical efforts are needed to understand and inform the public about these important but overlooked trends.

Non-vaccination of dogs is linked to uncompleted COVID-19 vaccination protocols of owners

Despite the known importance of vaccines as one of the greatest achievements in medical science, vaccine hesitancy has been increasing in the last decade and has become a major threat to global health. The growth of vaccine hesitancy worldwide became more evident with the onset of COVID-19 and raised the fear that this hesitancy would also impact companion animal vaccination. This study aimed to characterize vaccine-hesitant groups regarding companion animals and human vaccinations, as well as to explore the possible association between vaccine hesitancy in pets and their owners. An anonymous online survey containing 27 closed questions was conducted, including questions about dog health, such as vaccination, neutering, and homeopathy use, as well as questions about the COVID-19 vaccination status of the owner and motivations for vaccinating or not vaccinating their pets. Most participants (81.5 %) reported receiving three or more doses of the COVID-19 vaccine. Not vaccinating against COVID-19 or having an incomplete vaccination protocol was associated with an increase in the age range of participants (odds ratio [OR] = 1.43), not having higher education (OR = 7.70), and being in extreme income ranges (less than two minimum wages [OR = 7.57] and more than 10 [OR = 5.20]). The use of homeopathy in humans (OR = 3.24) and dogs (OR = 3.74) was associated with non-vaccination against COVID-19. Owners who were not fully vaccinated against COVID-19 were almost six times more likely to not vaccinate their dogs (OR = 5.94). Non-vaccination of dogs was also associated with non-neutering (OR = 3.56), keeping the dog in contact with other dogs (OR = 2.09), and an increase in the number of dogs in the house increased the chance of not vaccinating the animals (OR = 1.30). The present study revealed a strong association between non-vaccination against COVID-19 and non-vaccination in companion dogs, raising the hypothesis that vaccination hesitancy is a growing challenge in veterinary medicine. In addition, the characteristics of Brazilians who are reluctant to be vaccinated against COVID-19 or immunize their companion animals are described here for the first time.

Parental anxiety and pediatric vaccine refusal in a US national sample of parents

OBJECTIVES

Understanding vaccine hesitancy among parents is of emerging interest and of rising importance for promoting vaccine uptake to prevent pediatric illness. Here, we examine associations between pediatric vaccine refusal and parental symptoms of anxiety.

METHODS

Our cross-sectional survey assessed pediatric vaccine refusal in 1699 parents in a US national sample. Participants completed a sociodemographic questionnaire, the Vaccine Hesitancy Scale, and symptoms of anxiety (GAD-7).

RESULTS

The prevalence of pediatric vaccine refusal was 15.5 %. Parent symptoms of anxiety were related to vaccine refusal (OR = 1.07 [1.03, 1.10]). Mild (1.88 [1.39, 2.54], p <.001) and clinically significant (2.14 [1.39, 3.31], p <.001) symptoms of anxiety were also related to pediatric vaccine refusal. Parental anxiety was also associated with perceived risks of vaccines and reduced confidence.

CONCLUSIONS

Findings highlight the need to consider parental anxiety in the development of public health interventions that address substandard pediatric vaccine uptake.

Childhood vaccine refusal and what to do about it: a systematic review of the ethical literature

BACKGROUND

Parental refusal of routine childhood vaccination remains an ethically contested area. This systematic review sought to explore and characterise the normative arguments made about parental refusal of routine vaccination, with the aim of providing researchers, practitioners, and policymakers with a synthesis of current normative literature.

METHODS

Nine databases covering health and ethics research were searched, and 121 publications identified for the period Jan 1998 to Mar 2022. For articles, source journals were categorised according to Australian Standard Field of Research codes, and normative content was analysed using a framework analytical approach.

RESULTS

Most of the articles were published in biomedical journals (34%), bioethics journals (21%), and journals that carry both classifications (20%). Two central questions dominated the literature: (1) Whether vaccine refusal is justifiable (which we labelled 'refusal arguments'); and (2) Whether strategies for dealing with those who reject vaccines are justifiable ('response arguments'). Refusal arguments relied on principlism, religious frameworks, the rights and obligations of parents, the rights of children, the medico-legal best interests of the child standard, and the potential to cause harm to others. Response arguments were broadly divided into arguments about policy, arguments about how individual physicians should practice regarding vaccine rejectors, and both legal precedents and ethical arguments for vaccinating children against a parent's will. Policy arguments considered the normative significance of coercion, non-medical or conscientious objections, and possible reciprocal social efforts to offset vaccine refusal. Individual physician practice arguments covered nudging and coercive practices, patient dismissal, and the ethical and professional obligations of physicians. Most of the legal precedents discussed were from the American setting, with some from the United Kingdom.

CONCLUSIONS

This review provides a comprehensive picture of the scope and substance of normative arguments about vaccine refusal and responses to vaccine refusal. It can serve as a platform for future research to extend the current normative literature, better understand the role of cultural context in normative judgements about vaccination, and more comprehensively translate the nuance of ethical arguments into practice and policy.

Barriers to measles mumps rubella vaccine acceptance in the three southern border provinces of Thailand

Purpose

This qualitative study utilizing phenomenological methodology aimed to depict parental measles mumps rubella (MMR) vaccine acceptance through the work experiences of health personnel.

Materials and Methods

Twenty-two public health workers working as vaccination providers in the three southern border provinces of Thailand were recruited. In-depth, face-to-face, semi-structured interviews were conducted. Data were analyzed using thematic analysis.

Results

Four main themes emerged: (1) religious beliefs, (2) personal disagreements, (3) fear and mistrust regarding potential vaccine side effects, and (4) misperceptions about the potential severity of measles. Four subthemes were identified: (1) haram (prohibited), (2) the will of Allah, (3) spousal disagreement, and (4) disagreement from a religious leader. The results of this study indicated that perceived religious prohibition was the most important reason for refusing to vaccinate among Muslim parents. Vaccine-hesitant parents were concerned that the vaccine might contain gelatin derived from pig products. Also, halal certification of the vaccine was required from Muslim parents to ensure that vaccine has been approved for Muslims. Meanwhile, a lack of knowledge and positive attitudes concerning immunizations of vaccine-hesitant parents were also found as predominant reasons for incomplete childhood immunizations in the deep south of Thailand.

Conclusion

Health education and engagement by religious leaders to endorse the vaccination and bridge the gap between religious beliefs and vaccine acceptance is needed to overcome this issue. This study findings could be effectively applied to improve vaccination uptake in a Muslim majority context.

Vaccine hesitancy in pregnant Women: A narrative review

Pregnant women are often at higher risk for morbidity and mortality due to contracting vaccine-preventable diseases that result in adverse pregnancy outcomes such as spontaneous abortion, preterm births, and congenital fetal defects. For example, health care provider recommendation is correlated with maternal acceptance of influenza vaccination, however, up to 33 % of pregnant women remain unvaccinated irrespective of provider recommendation. Vaccine hesitancy is a multifactorial problem that both the medical and public health systems need to address synergistically. Vaccine education should incorporate balanced perspectives to deliver vaccine education. This narrative review addresses four questions: 1) what are the primary concerns of pregnant women that lead them to be hesitant about receiving vaccinations; 2) to what extent does the source (e.g. provider, friend, family) of vaccine advice and information influence a pregnant person's decision to accept a vaccine; 3) how does the delivery method of vaccine education influence their decision; 4) how can categorizing patients into four distinct groups based on their opinions and behavior regarding vaccines be used to improve provider-patient communication and increase vaccine acceptance. Results from the literature show that the three most common reasons for vaccine hesitancy include: i.) fear of side effects or adverse events; ii.) lack of confidence in vaccine safety; iii.) low perception of being at high risk of infection during pregnancy and/or not having previously received the vaccination when not pregnant. We conclude that vaccine hesitancy is dynamic therefore people do not always hold a static level of vaccine hesitancy. People may move between a continuum of vaccine hesitancy for a multifactorial reasons. A framework, characterized by levels of vaccine hesitancy before and during pregnancy, was constructed to help providers find balance between promoting individual health and public health while providing vaccine education.

The societal cost of vaccine refusal: A modelling study using measles vaccination as a case study

BACKGROUND

Increasing vaccine hesitancy and refusal poses a challenge to public health as even small reductions in vaccine uptake can result in large outbreaks of infectious diseases. Here we estimate the societal costs of vaccine refusal using measles as a case study.

METHODS

We developed a compartmental metapopulation model of measles transmission to explore how the changes in the size and level of social mixing between populations that are "pro-vaccination", and "anti-vaccination" impacts the burden of measles. Using the projected cases and deaths, we calculated the health, healthcare, direct medical costs, and productivity loss associated with vaccine refusal. Using measles in England as a case study, we quantified the societal costs that each vaccine refusal imposes on society.

FINDINGS

When there is a high level of mixing between the pro- and anti-vaccination populations, those that refuse to be vaccinated benefit from the herd immunity afforded by the pro-vaccination population. At the same time, their refusal to be vaccinated increases the burden in those that are vaccinated due to imperfect vaccines, and in those that are not able to be vaccinated due to other underlying health conditions. Using England as a case study, we estimate that this translates to a societal loss of GBP 292 million and disease burden of 17 630 quality-adjusted-life-years (sensitivity range 10 594-50 379) over a 20-year time horizon. Of these costs, 26 % are attributable to healthcare costs and 74 % to productivity losses for patients and their carers. This translates to a societal loss per vaccine refusal of GBP 162.21 and 0.01 (0.006-0.03) quality-adjusted-life-years.

INTERPRETATION

Our findings demonstrate that even low levels of vaccine refusal can have a substantial and measurable societal burden on the population. These estimates can support the value of investment in interventions that address vaccine hesitancy and vaccine refusal, providing not only improved public health but also potential economic benefits to society.

Spatial distribution and determinants of childhood vaccination refusal in the United States

Parental refusal and delay of childhood vaccination has increased in recent years in the United States. This phenomenon challenges maintenance of herd immunity and increases the risk of outbreaks of vaccine-preventable diseases. We examine US county-level vaccine refusal for patients under five years of age collected during the period 2012-2015 from an administrative healthcare dataset. We model these data with a Bayesian zero-inflated negative binomial regression model to capture social and political processes that are associated with vaccine refusal, as well as factors that affect our measurement of vaccine refusal. Our work highlights fine-scale socio-demographic characteristics associated with vaccine refusal nationally, finds that spatial clustering in refusal can be explained by such factors, and has the potential to aid in the development of targeted public health strategies for optimizing vaccine uptake.

COVID-19 vaccination refusal and suspension of work among healthy healthcare personnel in Italy: A cross-sectional study of their knowledge and attitudes toward vaccinations

Despite the initial optimistic projections from various countries and the evidence that vaccination against coronavirus disease 2019 (COVID-19) reduces the associated hospitalization rates and mortality, vaccine hesitancy and refusal among healthcare personnel (HCP) became a major public health concern globally. The aim of this survey was to estimate the knowledge about the Italian Vaccination Plan for HCP and attitudes about occupational vaccinations for HCP among Italian HCP who refused COVID-19 vaccination and were suspended from work. A total of 52 HCP participated in the study. Nurses were the prevalent profession among vaccination refusers. About COVID-19, 24 (26.2%) of all responders have been involved in COVID-19 care and 21 (40.4%) had a history of COVID-19. None had received influenza and pneumococcus vaccination in the past. Knowledge of vaccinations recommended for HCP was high, ranging from 75% to 98% by vaccine. Instead, all HCP were against any mandatory vaccination policy for all HCP. Finally, most HCP questioned the expected benefits and safety of vaccines in general, raised issues of mistrust of information provided for authorities and of compliance with their HCP' vaccination recommendations. Our study indicates good knowledge of occupational vaccinations but strong anti-vaccination beliefs among Italian HCP who refused COVID-19 vaccination and were suspended from work.

Vaccination coverage in children in the period before and during the COVID-19 pandemic in Brazil: a time series analysis and literature review

OBJECTIVE

To evaluate the behavior of VCR and VCH, per municipality and per vaccines offered at the NVC, to identify priority areas for intervention.

METHODS

Descriptive study of a time series, using secondary data and accompanied by a narrative review of the literature evaluating VCR and VCH. Vaccines offered to children under one year and to those aged one year in the pre-pandemic period of COVID-19 (2015 to 2019) were selected and compared to those offered during the pandemic period (2020 and 2021).

RESULTS AND DISCUSSIONS

The decrease in VCR and VCH is a process that precedes the COVID-19 pandemic but was intensified during this period. In 2021, the VCR was around 70% for most vaccines. This phenomenon encompasses the entire country; however, it is more intense in the states/municipalities located in the north and northeast regions, suggesting greater difficulty in accessing health services.

CONCLUSIONS

Low and heterogeneous VCR requires the adoption of practices that were previously implemented, establishing partnerships with governmental and non-governmental institutions, with adequate communication, active search for non-compliance and non-adherence to the regular vaccination program, adopting intra- and extramural vaccination strategies, to reverse the current situation and reduce the risk of recurrence of diseases that have been already controlled and eliminated.

Childhood vaccine hesitancy in two regions with different socioeconomic backgrounds in Turkey

Aim

This study investigated childhood vaccine hesitancy in two regions with different socioeconomic backgrounds in Kayseri, Turkey.

Subject and methods

The study population consisted of all people over 18 years of age admitted to two family health centers (No 65 and 103) in a city center for any reason.

Results

Participants living in the high socioeconomic status (SES) region had a significantly lower mean rating on the CVHQ (Childhood Vaccine Hesitancy Questionnaire - see below) than those living in the low SES region.

Conclusion

Vaccine hesitancy is the main reason for vaccine refusal. Therefore, authorities should provide adequate and accurate information about the significance of vaccines to raise public awareness.

COVID-19 vaccine refusal associated with health literacy: findings from a population-based survey in Korea

BACKGROUND

Poor health literacy is associated with lower utilization of preventable services. However, the relationship between health literacy and COVID-19 vaccine hesitancy remains controvertible.

METHODS

This study used data from 229,242 individuals who completed the Community Health Survey in Korea from August 16 to October 31 in 2021. To operationalize COVID-19 vaccine hesitancy, we measured vaccine refusal, which is defined as not having been vaccinated and not intending to get vaccinated against COVID-19. Health literacy is operationalized in two dimensions; the ability to understand spoken directions from health professionals and the ability to understand written information regarding health. Covariates include sex, age, educational level, marital status, employment status, basic living security pension status, and subjective health status. Two multivariable logistic regression models were run to determine factors associated with COVID-19 vaccine refusal. Model 1 included sociodemographic characteristics and subjective health status. Model 2 added two health literacy variables. Odds ratio (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

Only 3.9% of the Korean adult population were estimated to refuse COVID-19 vaccine. The most commonly cited reasons for COVID-19 vaccine refusal were concerns about vaccine adverse events (47.6%), followed by the assessment of one's own health status (29.5%). Individuals who found spoken directions very difficult to understand were more likely to refuse COVID-19 vaccine than those who found spoken directions very easy (OR = 1.55, 95% CI: 1.28-1.87, p < 0.001). People who did not pay attention to written information were more likely to refuse COVID-19 vaccine than those who reported it to be very easy to understand (OR = 1.28, 95% CI: 1.13-1.45, p < 0.001). People in all other categories of the literacy spectrum for either spoken or written information did not have an increased risk of COVID-19 vaccine refusal.

CONCLUSION

Health literacy was significantly associated with COVID-19 vaccine refusal. Health literacy programs could be beneficial to reduce vaccine refusal, particularly for the people who find spoken directions from health professionals very difficult to understand and those who do not pay attention to written information.

Measurement of provider fidelity to immunization guidelines: a mixed-methods study on the feasibility of documenting patient refusals of the human papillomavirus vaccine

BACKGROUND

Assessment and feedback is a common implementation strategy to improve healthcare provider fidelity to clinical guidelines. For immunization guidelines, fidelity is often measured with doses administered during eligible visits. Adding a patient refusal measure captures provider fidelity more completely (i.e., all instances of a provider recommending a vaccine, resulting in vaccination or refusal) and enables providers to track patient vaccine hesitancy patterns. However, many electronic health record (EHR) systems have no structured field to document multiple instances of refusals for specific vaccines, and existing billing codes for refusal are not vaccine specific. This study assessed the feasibility of a novel method for refusal documentation used in a study focused on human papillomavirus (HPV) vaccine.

METHODS

An observational, descriptive-comparative, mixed-methods study design was used to conduct secondary data analysis from an implementation-effectiveness trial. The parent trial compared coach-based versus web-based practice facilitation, including assessment and feedback, to increase HPV vaccination in 21 community-based private pediatric practices. Providers were instructed to document initial HPV vaccine refusals in the EHR's immunization forms and subsequent refusals using dummy procedure codes, for use in assessment and feedback reports. This analysis examined adoption and maintenance of the refusal documentation method during eligible well visits, identified barriers and facilitators to documentation and described demographic patterns in patient refusals.

RESULTS

Seven practices adopted the refusal documentation method. Among adopter practices, documented refusals started at 2.4% of eligible well visits at baseline, increased to 14.2% at the start of implementation, peaked at 24.0%, then declined to 18.8%. Barriers to refusal documentation included low prioritization, workflow integration and complication of the billing process. Facilitators included high motivation, documentation instructions and coach support. Among adopter practices, odds of refusing HPV vaccine were 25% higher for patients aged 15-17 years versus 11-12 years, and 18% lower for males versus females.

CONCLUSIONS

We demonstrated the value of patient refusal documentation for measuring HPV vaccination guideline fidelity and ways that it can be improved in future research. Creation of vaccine-specific refusal billing codes or EHR adaptations to enable documenting multiple instances of specific vaccine refusals would facilitate consistent refusal documentation. Trial Registration NCT03399396 Registered in ClinicalTrials.gov on 1/16/2018.

The influence of social class and institutional relationships on the experiences of vaccine-hesitant mothers: a qualitative study

BACKGROUND

Vaccine hesitancy is a growing problem in the United States. However, our understanding of the mechanisms by which socioeconomic status (SES) shapes the experience of vaccine hesitancy and decision-making is incomplete.

AIM

The aim of this study was to understand how social class influences the experiences and perspectives of vaccine-hesitant mothers.

METHODS

We conducted semistructured interviews with middle- and working-class vaccine-hesitant mothers. Participants were identified through neighborhood parenthood groups in the Philadelphia area, as well as in-person and online groups whose members express concerns about vaccines. Interviews were audio recorded and inductively analyzed.

RESULTS

Interviews were conducted with 37 vaccine-hesitant mothers, who described their vaccine decision-making through the lens of interactions with three institutional stakeholders: 1) pediatric clinicians; 2) school administrators; and 3) emergency room staff. In discussing these interactions, middle- and working-class mothers invoked distinct levels of authority in relation to these institutions. Specifically, working-class mothers expressed concerns that medical or school professionals could act as reporters for state intervention, including Child Protective Services, while middle-class mothers did not. These interactions highlighted the ways middle- and working-class mothers in our study felt differently empowered and constrained in their vaccine choices, and ultimately influenced their perceptions of available actions.

CONCLUSIONS

Our findings indicate that experiences of vaccine hesitancy may be influenced by mothers' social class via their relationships to institutional authorities. These findings have implications for how clinicians communicate with parents from different social backgrounds to best build trust and facilitate vaccine uptake.

Decision making in vaccine hesitant parents and pregnant women - An integrative review

Objectives

: Vaccine refusal is increasing in Australia and is a major concern in high- and middle-income countries. There is evidence to suggest that some parents, even those who elect to immunise, may be vaccine hesitant with some manipulating the schedule by excluding or delaying some vaccines. The aim of this review was to gain an understanding of factors that influence vaccine decision-making in pregnant women and parents of children.

Design

: An integrative review approach was used to produce an analysis of existing literature on vaccine decision-making in pregnancy and parents. As the broadest of review methods, an integrative review can include a range of experimental and non-experimental research, thereby ensuring the inclusion of data from multiple perspectives.

Data Sources

: Online databases were searched for research related to vaccine decision-making in pregnant women and parents. Original and review articles were sought that were published in English between 2015 and 2021. Reviewed articles included qualitative and quantitative studies and systematic reviews. No mixed methods papers were located or excluded from this review.

Review methods

: The review method was an integrative review informed by Coughlan.

Results

: Papers from thirteen predominantly high- and middle-income countries were selected for this review. A total of 31 articles fit the inclusion/exclusion criteria, including qualitative, quantitative and review articles. Three main themes were identified including the role of healthcare professionals, vaccine safety concerns and alternative influences. Alternative influences included: social media, friends and family, religion, conspiracy theories and salutogenic parenting. Findings suggest that high levels of anxiety are involved in vaccine decision-making with parents seeking information from multiple sources including healthcare professionals, friends and family and social media.

Conclusions

: Pregnancy is an ideal time to provide education on both pregnancy and childhood vaccinations. However, some parents reported dissatisfaction in their therapeutic relationships with healthcare professionals. As a result, parents can resort to their own information seeking, in the main via social media which has been linked to vaccine refusal. Additionally, some healthcare professionals report feeling inadequately prepared for the role of immunisation promotion and provision. Parental information seeking from non-traditional sources has been shown to result in the acquisition of misinformation, exposure to conspiracy theories, the inevitable loss of vaccine confidence and subsequent vaccine refusal.

Best shot: A motivational interviewing approach to address vaccine hesitancy in pediatric outpatient settings

BACKGROUND

Vaccine hesitancy in parents and childhood vaccine refusal is increasing. A standard of care to address this problem has not been identified.

PURPOSE

To identify if the use of motivational interviewing by pediatric providers during routine well child visits, when compared to standard of care, would increase vaccine rates in children 0-12 months of age. Factors associated with vaccine hesitancy were also investigated.

METHODS

A quasi-experimental study was completed on a convenience sample of pediatric providers (N = 6) and caregivers of children 0-12 months of age (N = 66). Four providers were trained to use motivational interviewing. During the well child visit the Parent Attitudes About Childhood Vaccines survey was completed, and the motivational interviewing intervention was implemented. Clinic's data were compared with other clinic data of non-trained providers.

FINDINGS

Vaccine refusal/delays rate was 11.4% among caregivers. Vaccine refusal rate decreased after the intervention (9.00% pre-intervention and 6.40% post-intervention). An ordinal regression identified caregivers with higher vaccine hesitancy scores and more children were more likely to delay or refuse vaccines, while caregivers ≥30 years or with high income were less likely to delay/refuse vaccines. A difference in difference analysis identified that an additional 2.6% of children received vaccines when seen by trained providers compared to non-trained (β = -0.330, OR = 0.719, p = 0.470).

DISCUSSION

Findings indicate a condensed motivational interviewing education session may be clinically significant in decreasing vaccine hesitancy among this population.

APPLICATIONS TO PRACTICE

A more robust study to confirm these findings is recommended prior to practice implementation.

Understanding parental vaccine refusal: Implicit and explicit associations about vaccines as potential building blocks of vaccine beliefs and behavior

Objective

A movement of parents refusing vaccines for their children has contributed to increasingly large outbreaks of diseases that are preventable by vaccines. Research has identified multiple factors that relate to parents' vaccination behaviors (i.e., whether not they vaccinate their children), including their beliefs about vaccines' safety and utility and their trust in those who recommend vaccines. Here we examine the role of more fundamental psychological processes that may contribute to multiple vaccine-related beliefs and behaviors: cognitive associations.

Methods

Using a large sample of U.S. parents (pre-COVID-19), we investigated parents' associations between vaccines and helpfulness/harmfulness, as well as between the self and vaccines (vaccine identity), and their relation to parents' beliefs about vaccine safety and utility, trust in authorities' vaccine recommendations, and prior vaccination refusal for their children. To capture a more complete understanding of people's associations, we examined both explicit associations (measured via self-report) and implicit associations (measured by the Implicit Association Test).

Results

Both implicit and explicit associations correlated with beliefs, trust, and vaccination refusal. Results from structural equation models indicated that explicit vaccine-identity and vaccine-helpfulness associations and implicit vaccine helpfulness associations were indirectly related to vaccination refusal via their relation with vaccine beliefs.

Conclusions

Collectively, study findings suggest that vaccine associations—especially those related to helpfulness/harmfulness—may serve as psychological building blocks for parental vaccine beliefs and behaviors.

Vaccine Hesitancy in Pediatrics

Vaccine hesitancy is a growing complex and multifaceted phenomenon. It encompasses a wide spectrum of context-dependent attitudes and beliefs. Multiple factors influence parental decision-making including knowledge, sources of information, risk perception, trust, and individual experiences among others. This review focuses on describing the most common reasons that contribute to vaccine hesitancy among parents. Social media and the Internet have been described as major elements that can negatively influence parental decision-making regarding vaccines. The next focus is describing effective interventions that clinical providers can apply. Nonconfrontational and open discussions along with trusting and strong relationships between parents and providers seem to create a solid foundation toward vaccine acceptance. In addition, motivational interviewing is a helpful tool that has proven to be effective during these discussions. Ultimately, an individualized approach tailored to a specific community will likely be most effective in addressing vaccine hesitancy.

The willingness of parents to vaccinate their children younger than 12 years against COVID-19: a cross-sectional study in Malaysia

Background

The initiation of a new drug, for instance, the coronavirus disease 2019 (COVID-19) vaccine in children could be a source of major concern for parents. This study aims to determine the willingness of parents in Malaysia to vaccinate their children younger than 12 years against COVID-19.

Methods

An online cross-sectional survey was conducted nationwide in Malaysia from August 29, 2021, to October 17, 2021. Parents with children younger than 12 years were enrolled via the snowball sampling method.

Results

The analysis included data from 3,528 parents (79.5%) of the 4,438 survey responses received. Of these parents, 2,598 (73.6%) were willing, 486 (13.8%) were not willing, and 444 (12.6%) were still hesitant to vaccinate their children against COVID-19. Single parents (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.32–3.04; P = 0.001), parents with secondary or lower education (OR, 1.5; 95% CI, 1.21–1.96; P < 0.001), healthcare workers (OR, 1.7; 95% CI, 1.34–2.26; P < 0.001), parents who had significant contact with COVID-19 (OR, 1.3; 95% CI, 1.09–1.63; P = 0.006), and parents who had been vaccinated against COVID-19 (OR, 15.4; 95% CI, 9.76–24.33; P < 0.001) were found more willing to immunize their children. The common reasons for vaccination given by parents who were willing to immunize their children include protection of children (99.4%), protection of other family members (99.3%), and effectiveness (98.2%). The common reasons against vaccination given by parents who were not willing to immunize their children were uncertainty about the new vaccine (96.1%), concerns about vaccine contents (93.2%), limited vaccine information from physicians (82.3%), and the belief of vaccine was unsafe (79.8%).

Conclusions

In this study, nearly three-quarters of parents were willing to vaccinate their children younger than 12 years against COVID-19. The parents’ history of COVID-19 vaccination was the strongest independent predictor of their willingness to vaccinate their children. Therefore, future health education for the COVID-19 vaccine should focus on parents who are prone to vaccine refusal or hesitation, address the common reasons for vaccine refusal, and highlight the vaccine’s benefits.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13682-z.

Strategies to overcome vaccine hesitancy: a systematic review

BACKGROUND

Vaccination, albeit a necessity in the prevention of infectious diseases, requires appropriate strategies for addressing vaccine hesitancy at an individual and community level. However, there remains a glaring scarcity of available literature in that regard. Therefore, this review aims to scrutinize globally tested interventions to increase the vaccination uptake by addressing vaccine hesitancy at various stages of these interventions across the globe and help policy makers in implementing appropriate strategies to address the issue.

METHODS

A systematic review of descriptive and analytic studies was conducted using specific key word searches to identify literature containing information about interventions directed at vaccine hesitancy. The search was done using PubMed, Global Health, and Science Direct databases. Data extraction was based on study characteristics such as author details; study design; and type, duration, and outcome of an intervention.

RESULTS

A total of 105 studies were identified of which 33 studies were included in the final review. Community-based interventions, monetary incentives, and technology-based health literacy demonstrated significant improvement in the utilization of immunization services. On the other hand, media-based intervention studies did not bring about a desired change in overcoming vaccine hesitancy.

CONCLUSION

This study indicates that the strategies should be based on the need and reasons for vaccine hesitancy for the targeted population. A multidimensional approach involving community members, families, and individuals is required to address this challenging issue.

Predictors of uncertainty and unwillingness to receive the COVID-19 booster vaccine: An observational study of 22,139 fully vaccinated adults in the UK

BACKGROUND

The continued success of the COVID-19 vaccination programme in the UK will depend on widespread uptake of booster vaccines. However, there is evidence of hesitancy and unwillingness to receive the booster vaccine, even in fully vaccinated adults. Identifying factors associated with COVID-19 booster vaccine intentions specifically in this population is therefore critical.

METHODS

We used data from 22,139 fully vaccinated adults who took part in the UCL COVID-19 Social Study. Multinomial logistic regression examined predictors of uncertainty and unwillingness (versus willingness) to receive a COVID-19 booster vaccine (measured 22 November 2021 to 6 December 2021), including (i) socio-demographic factors, (ii) COVID-19 related factors (e.g., having been infected with COVID-19), and (iii) initial intent to receive a COVID-19 vaccine in the four months following the announcement in the UK that the vaccines had been approved (2 December 2020 to 31 March 2021).

FINDINGS

4% of the sample reported that they were uncertain about receiving a COVID-19 booster vaccine, and a further 4% unwilling. Initial uncertainty and unwillingness to accept the first COVID-19 vaccine in 2020-21 were each associated with over five times the risk of being uncertain about and unwilling to accept a booster vaccine. Healthy adults (those without a pre-existing physical health condition) were also more likely to be uncertain or unwilling to receive a booster vaccine. In addition, low levels of current stress about catching or becoming seriously ill from COVID-19, consistently low compliance with COVID-19 government guidelines during periods of strict restrictions (e.g., lockdowns), lower levels of educational qualification, lower socio-economic position, and age below 45 years were all associated with uncertainty and unwillingness.

INTERPRETATION

Our findings highlight that there are a range of factors that predict booster intentions, with the strongest predictor being previous uncertainty and unwillingness. Two other concerning patterns also emerged from our results. First, administration of booster vaccinations may increase social inequalities in experiences of COVID-19 as adults from lower socio-economic backgrounds are also most likely to be uncertain or unwilling to accept a booster vaccine as well as most likely to be seriously affected by the virus. Second, some of those most likely to spread COVID-19 (i.e., those with poor compliance with guidelines) are most likely to be uncertain and unwilling. Public health messaging should be tailored specifically to these groups.

FUNDING

The Nuffield Foundation [WEL/FR-000022583], the MARCH Mental Health Network funded by the Cross-Disciplinary Mental Health Network Plus initiative supported by UK Research and Innovation [ES/S002588/1], and the Wellcome Trust [221400/Z/20/Z and 205407/Z/16/Z].

Listening to vaccine refusers

In bioethics vaccine refusal is often discussed as an instance of free riding on the herd immunity of an infectious disease. However, the social science of vaccine refusal suggests that the reasoning behind refusal to vaccinate more often stems from previous negative experiences in healthcare practice as well as deeply felt distrust of healthcare institutions. Moreover, vaccine refusal often acts like an exit mechanism. Whilst free riding is often met with sanctions, exit, according to Albert Hirschman's theory of exit and voice is most efficiently met by addressing concerns and increasing the quality and number of feedback channels. If the legitimate grievances responsible for vaccine refusal are not heard or addressed by healthcare policy, further polarization of attitudes to vaccines is likely to ensue. Thus, there is a need in the bioethics of vaccine refusal to understand the diverse ethical questions of this inflammable issue in addition to those of individual responsibility to vaccinate.

Stigmatized for standing up for my child: A qualitative study of non-vaccinating parents in Australia

BACKGROUND

Vaccine refusal is highly polarizing in Australia, producing a challenging social landscape for non-vaccinating parents. We sought to understand the lived experience of non-vaccinating parents in contemporary Australia.

METHODS

We recruited a national sample of non-vaccinating parents of children <18 yrs, advertising on national radio, in playgrounds in low vaccination areas, and using snowballing. Grounded Theory methodology guided data collection (via semi-structured interviews). Inductive analysis identified stigmatization as a central concept; stigma theory was adopted as an analytical lens.

RESULTS

Twenty-one parents from regional and urban locations in five states were interviewed. Parent's described experiences point to systematic stigmatization which can be characterized using Link & Phelan's five-step process. Parents experienced (1) labelling and (2) stereotyping, with many not identifying with the "anti-vaxxers" portrayed in the media and describing frustration at being labelled as such, believing they were defending their child from harm. Participants described (3) social "othering", leading to relationship loss and social isolation, and (4) status loss and discrimination, feeling "brushed off" as incompetent parents and discriminated against by medical professionals and other parents. Finally, (5) legislative changes exerted power over their circumstances, rendering them unable to provide their children with the same financial and educational opportunities as vaccinated children, often increasing their steadfastness in refusing vaccination.

CONCLUSION

Non-vaccinating Australian parents feel stigmatized for defending their child from perceived risk of harm, reporting a range of social and psychological effects, as well as financial effects from policies which disadvantaged their children through differential financial treatment, and diminished early childhood educational opportunities. While it might be argued that social stigma and exclusionary policies directed a small minority for the greater good are justified, other more nuanced approaches based on better understandings of vaccine rejection could achieve comparable public health outcomes without the detrimental effect on unvaccinated families.

Racial differences in institutional trust and COVID-19 vaccine hesitancy and refusal

BACKGROUND

Previous research has indicated that demographic differences affect COVID-19 vaccination rates. Trust, in both the vaccine itself and institutional trust, is one possible factor. The present study examines racial differences in institutional trust and vaccine status among a nationally representative sample of adults in the United States.

METHODS

Data for the current study was collected as part of Wave 8 Omnibus 2000 survey conducted by RAND ALP and consisted of 2080 participants. Responses were collected through the online RAND ALP survey in March 2021.

RESULTS

Trust in the scientific community was the strongest predictor for already receiving at least one dose of the COVID-19 vaccine at the time of study. Asians had a significantly higher trust in the scientific community compared to all other groups. Results also showed a significant difference in level of trust of the government's response to the COVID-19 pandemic with Indian/Alaskan Natives reporting lower trust compared to Whites, Blacks and Asians. Asians also had a significantly higher level of trust when compared to those who identified as racial Other. Those who identify as American Indian/Alaskan Natives had the lowest levels of institutional trust. Trust in the government's response was not indicative of vaccination within the sample.

CONCLUSIONS

Strategies to increase trust of the scientific community can be employed to address vaccine hesitancy through community-based initiatives and building of partnerships between the scientific community and local community stakeholders.

Pharmacy student perceptions of their preparedness to address vaccine hesitancy and refusal

INTRODUCTION

Vaccine hesitancy/refusal is a growing issue worldwide. Pharmacists are well suited to address vaccine hesitancy; however, the extent to which they feel trained to do so may vary. The objective of this study was to determine pharmacy student confidence in addressing vaccine hesitancy/refusal.

METHODS

Students in their penultimate didactic and experiential years at United States schools of pharmacy were invited to participate in a 30-item electronic survey concerning perceptions of preparedness to address vaccine hesitancy/refusal. The primary outcome was pharmacy students' perception of their ability to address vaccine hesitancy/refusal. Secondary outcomes included student confidence in their knowledge of and ability to speak to vaccine controversies and support for pharmacist/patient vaccine responsibilities. Outcomes were addressed using five-point Likert-type items. Median values and interquartile ranges were reported, with chi-square analysis accounting for possible heterogeneity between groups.

RESULTS

A total of 1433 students (estimated response rate = 20%) completed the survey. Respondents indicated confidence in their preparedness to address patient immunization concerns, hesitancy, and refusal with a median score of 4 (scale of 5, with 1 = the least confident and 5 = the most confident). Secondary outcome analysis revealed varying degrees of confidence regarding specific vaccine hesitancy controversies.

CONCLUSIONS

Pharmacy students were confident in their ability to address vaccine hesitancy/refusal. Students held beliefs of responsibility for limiting non-vaccination, but felt less confident in addressing concerns regarding specific vaccine components and immune system overload.

Vaccine Hesitancy: Drivers and How the Allergy Community Can Help

Vaccine hesitancy-defined by the World Health Organization (WHO) as a "delay in acceptance or refusal of vaccines despite availability of vaccination services"-is not a recent phenomenon. Historical records indicate that vaccine hesitancy existed by the 18th century in Europe and even resulted in violent riots. The drivers of vaccine hesitancy have evolved over the last 200 years but not, perhaps, as much as one might expect. More problematic are the means by which concerns over vaccine hesitancy are communicated by a new landscape of digital communication, generating what has been described as an "infodemic" in which an overabundance of information-both factual and misinformation-contributes to hesitancy. In this review, we discuss the background and current drivers of vaccine hesitancy and the evidence base for strategies to combat this. We highlight the important role the allergy/immunology community could have in working to mitigate vaccine hesitancy, particularly with respect to the current coronavirus disease 2019 (COVID-19) pandemic.

Determinants of influenza vaccine hesitancy among pregnant women in Europe: a systematic review

BACKGROUND

Pregnant women are at high risk for severe influenza. However, maternal influenza vaccination uptake in most World Health Organization (WHO) European Region countries remains low, despite the presence of widespread national recommendations. An influenza vaccination reduces influenza-associated morbidity and mortality in pregnancy, as well as providing newborns with protection in their first months. Potential determinants of vaccine hesitancy need to be identified to develop strategies that can increase vaccine acceptance and uptake among pregnant women. The primary objective of the systematic review is to identify the individual determinants of influenza vaccine hesitancy among pregnant women in Europe, and how to overcome the hesitancy.

METHODS

Databases were searched for peer-reviewed qualitative and quantitative studies published between 2009 and 2019 inclusive. Databases included PubMed via MEDLINE, Cochrane Central Register for Controlled Trials, PsycINFO, SAGE Journals, Taylor and Francis and Springer nature. These covered themes including psychology, medicine, and public health. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach, 11 studies were eligible and analyzed for significant determinants of influenza vaccine hesitancy among pregnant women in Europe.

RESULTS

The most commonly reported factors were psychological aspects, for example concerns about safety and risks to mother and child, or general low risk perception of becoming ill from influenza. Doubts about the effectiveness of the vaccine and a lack of knowledge about this topic were further factors. There was also influence of contextual factors, such as healthcare workers not providing adequate knowledge about the influenza vaccine or the pregnant lady stating their antivaccine sentiment.

CONCLUSION

Health promotion that specifically increases knowledge among pregnant women about influenza and vaccination is important, supporting a valid risk judgment by the pregnant lady. The development of new information strategies for dialogue between healthcare providers and pregnant women should form part of this strategy.

Vaccine hesitancy and reported non-vaccination in an Irish pediatric outpatient population

Vaccine hesitancy is defined as a delay in acceptance, or refusal, of vaccines, despite availability. It is a complex and context specific phenomenon and identified as a global health priority. The "Parent Attitudes about Childhood Vaccines" (PACV) questionnaire is a validated tool for identifying vaccine hesitancy. Our aim was to use the PACV to assess vaccine hesitancy and its relationship with reported non-vaccination in an Irish population, for the first time. Our participants were parents or caregivers of children attending general pediatric clinics in a tertiary pediatric hospital in Dublin, Ireland, between September and December 2018. In total, 436 participants completed the questionnaire. 5.5% of our population reported non-vaccination. Human papilloma virus and measles, mumps, rubella vaccines were the most commonly cited vaccines of concern (11.5% and 6.7%, respectively), and autism spectrum disorder was the most commonly side effect of concern (4.3%). Mean PACV score was 26.9 (SD 19.1), with a significant difference between non-vaccinators and vaccinators (53.2 vs 25.3, p<0.001). Safety and efficacy concerns were the major contributor to non-vaccination. 14.4% of our population were vaccine-hesitant using the conventional cut-off score, which increased to 22% when using an optimal cut-off which maximized sensitivity and specificity. The accuracy of the PACV score to identify non-vaccination was good (area under the ROC curve = 0.827), and the optimal cut-off had a high negative predictive value (98.5%).Conclusion: PACV identified reported non-vaccination with high accuracy in our population. It may be useful to screen vaccine-hesitant parents who could benefit from interventions to improve uptake. What is Known: • Vaccine hesitancy is a leading threat to global health, with falls in vaccine uptake associated with disease outbreaks worldwide. • The Parent Attitudes about Childhood Vaccines (PACV) questionnaire is a validated measure of vaccine hesitancy and correlates with non-vaccination in many populations. What is New: • This large study in a pediatric outpatient clinic setting represents the first use of the PACV in a Western European population to assess vaccination hesitancy. • The PACV may be an effective way of screening a pediatric clinic population to identify vaccine-hesitant parents or caregivers for targeted vaccine promotion.

Discrepancies and Similarities in Attitudes, Beliefs, and Familiarity with Vaccination Between Religious Studies and Science Students in Malaysia: A Comparison Study

Little is known about the impact of religion on vaccine receptivity in Malaysia. Improved vaccine uptake is positively reflected in the reduction of vaccine-preventable diseases. This study aimed to explore and compare the attitudes, religious beliefs, and familiarity regarding vaccination between the religious studies and science students. A survey-based cross-sectional study was conducted between a convenient sample of students (N = 300) of religious studies and applied sciences in Kuantan, Malaysia. A new, face- and content-validated questionnaire was used for data collection. A total of 206 students responded to the questionnaire, giving a response rate of 86.6%. Overall, participants demonstrated positive attitudes towards vaccination (n = 185, 89.9%). Only a minority of respondents expressed an opposition to vaccination (n = 21, 10.2%). Religious factors (permissibility) of vaccines (n = 12, 57.1%) and harm associated with the vaccine (n = 13, 61.9%) were the most common reasons for not supporting vaccination among the non-supporters. Most (n = 135, 65.5%) respondents agreed that vaccination is parallel with the Islamic concept of protecting life and preventing harm. Almost half of the respondents (n = 98, 47.6%) admit to declaring "Fatwa" to oblige parents to vaccinate their children. Religious beliefs and safety issues surrounding immunisation were reported as the major barriers for the support of immunisation. Well-designed programs are recommended to reshape the religious beliefs and convictions among students toward vaccination.

Parental attitudes towards mandatory vaccination; a systematic review

Uptake of childhood vaccines is decreasing. While mandatory vaccination schemes can increase vaccine uptake rates, they can also cause backlash among some parents. We conducted a systematic review investigating parental beliefs about vaccine mandates and factors associated with support for mandatory vaccination schemes. We searched Embase, Ovid MEDLINE, Global Health, APA PsycINFO and Web of Science from inception to 17th September 2020. Seventeen studies (five qualitative, twelve quantitative) were eligible for inclusion. We synthesised results of qualitative and quantitative studies separately. As quantitative studies were heterogeneous in the mandatory vaccination schemes and associated factors investigated, there was no scope to conduct a meta-analysis. Instead, data were narratively synthesised, considering risk of bias ratings. Qualitative data were synthesised using meta-ethnography, synthesising themes reported across studies included. Quantitative studies reported that support for mandatory vaccination schemes was reasonably high (73% to 88%). However, due to heterogeneity, there was little evidence for any factors being consistently associated with support for mandatory vaccination. Qualitative studies gave an insight into how parents perceive mandatory vaccination. Studies found that parents perceived mandatory vaccination schemes as an infringement of their rights, and particularly disliked schemes offering financial incentives for vaccination. Nevertheless, some parents felt that schemes limiting access to schooling of unvaccinated children gave them "peace of mind." Results should be taken with caution due to the purposive use of non-representative samples. Before deciding to mandate vaccination, it is important to understand the impact it could have on parental beliefs and attitudes about vaccination.

Removing conscientious objection: The impact of 'No Jab No Pay' and 'No Jab No Play' vaccine policies in Australia

Vaccine refusal and hesitancy pose a significant public health threat to communities. Public health authorities have been developing a range of strategies to improve childhood vaccination coverage. This study examines the effect of removing conscientious objection on immunisation coverage for one, two and five year olds in Australia. Conscientious objection was removed from immunisation requirement exemptions for receipt of family assistance payments (national No Jab No Pay) and enrolment in childcare (state No Jab No Play). The impact of these national and state-level policies is evaluated using quarterly coverage data from the Australian Immunisation Register linked with regional data from the Australian Bureau of Statistics at the statistical area level between 2014 and 2018. Results suggest that there have been overall improvements in coverage associated with No Jab No Pay, and states that implemented additional No Jab No Play and tightened documentation requirement policies tended to show more significant increases. However, policy responses were heterogeneous. The improvement in coverage was largest in areas with greater socioeconomic disadvantage, lower median income, more benefit dependency, and higher pre-policy baseline coverage. Overall, while immunisation coverage has increased post removal of conscientious objection, the policies have disproportionally affected lower income families whereas socioeconomically advantaged areas with lower baseline coverage were less responsive. More effective strategies require investigation of differential policy effects on vaccine hesitancy, refusal and access barriers, and diagnosis of causes for unresponsiveness and under-vaccination in areas with persistently low coverage, to better address areas with persistent non-compliance with accordant interventions.

Attitudes towards vaccines and intention to vaccinate against COVID-19: Implications for public health communications

BACKGROUND

Negative attitudes towards vaccines and an uncertainty or unwillingness to receive vaccinations are major barriers to managing the COVID-19 pandemic in the long-term. We estimate predictors of four domains of negative attitudes towards vaccines and identify groups most at risk of uncertainty and unwillingness to receive a COVID-19 vaccine in a large sample of UK adults.

METHODS

Data were cross-sectional and from 32,361 adults in the UCL COVID-19 Social Study. Ordinary least squares regression analyses examined the impact of socio-demographic and COVID-19 related factors on four types of negative vaccine attitudes: mistrust of vaccine benefit, worries about unforeseen effects, concerns about commercial profiteering, and preference for natural immunity. Multinomial regression examined the impact of socio-demographic and COVID-19 related factors, negative vaccine attitudes, and prior vaccine behaviour on uncertainty and unwillingness to be vaccinated for COVID-19.

FINDINGS

16% of respondents displayed high levels of mistrust about vaccines across one or more domains. Distrustful attitudes towards vaccination were higher amongst individuals from ethnic minority backgrounds, with lower levels of education, lower annual income, poor knowledge of COVID-19, and poor compliance with government COVID-19 guidelines. Overall, 14% of respondents reported unwillingness to receive a vaccine for COVID-19, whilst 23% were unsure. The largest predictors of both COVID-19 vaccine uncertainty and refusal were low-income groups (< £16,000, a year), having not received a flu vaccine last year, poor adherence to COVID-19 government guidelines, female gender, and living with children. Amongst vaccine attitudes, intermediate to high levels of mistrust of vaccine benefit and concerns about future unforeseen side effects were the most important determinants of both uncertainty and unwillingness to vaccinate against COVID-19.

INTERPRETATION

Negative attitudes towards vaccines are a major public health concern in the UK. General mistrust in vaccines and concerns about future side effects in particular will be barriers to achieving population immunity to COVID-19 through vaccination. Public health messaging should be tailored to address these concerns and specifically to women, ethnic minorities, and people with lower levels of education and incomes.

FUNDING

The Nuffield Foundation [WEL/FR-000022583], the MARCH Mental Health Network funded by the Cross-Disciplinary Mental Health Network Plus initiative supported by UK Research and Innovation [ES/S002588/1], and the Wellcome Trust [221400/Z/20/Z and 205407/Z/16/Z].

Vaccine sentiments and under-vaccination: Attitudes and behaviour around Measles, Mumps, and Rubella vaccine (MMR) in an Australian cohort

OBJECTIVE

The study aimed to examine the consistency in factors associated with attitudes towards vaccination and MMR vaccination status.

METHODS

Using the nationally representative Longitudinal Study of Australian Children matched with the Australian Childhood Immunisation Register, 4,779 children were included from 2004-2005 to 2010-11. Different MMR vaccine dosages and general attitude towards vaccination were modelled individually with multinomial logit regressions, controlling for demographic, socioeconomic, and health related factors of the children and their primary carers.

RESULTS

The group with non-vaccination and negative attitudes was characterised by more siblings and older parents the group with under-vaccination but positive attitudes was characterised by younger parental age; and the group with under-vaccination and neutral attitudes was characterised by less socioeconomically advantaged areas. The presence of parental medical condition(s), being private or public renters, and higher parental education were associated with under-vaccination but not with attitudes towards vaccination, whilst parental religion was associated with attitudes towards vaccination but not reflected in the vaccine uptake.

CONCLUSIONS

Vaccine attitudes were largely consistent with MRR vaccine outcomes. However, there was variation in the associations of factors with vaccine attitudes and uptake. The results have implications for different policy designs that target subgroups with consistent or inconsistent vaccination attitudes and behaviour. Parents with intentional and unintentional under-vaccination are of policy concern and require different policy solutions.

Unvaccinated children as community parasites in National Qualitative Study from Turkey

Background

This national qualitative study explores (1) the experiences, observations, and opinions of health care workers (HCWs) about beliefs, socioeconomic, cultural, and environmental characteristics of parents refusing vaccination and (2) regional differences in the identified risk factors; (3) recommended solutions to improve vaccine acceptance in each of 12 regions in Turkey.

Methods

In total, we carried out 14 individual semi-structured in-depth interviews and 10 focus group discussions with 163 HCWs from 36 provinces. A thematic analysis was performed to explore HCWs’ observations about the parents’ decisions to reject vaccination and possible solutions for vaccine advocacy.

Results

Within the analyzed data framework, vaccine refusal statements could be defined as vaccine safety, the necessity of vaccines, assumptions of freedom of choice, health workers’ vaccine hesitancy, lack of information about national vaccination schedule and components, not trusting the health system, anti-vaccine publications in social media and newspapers, and refugees. Suggestions based on the HCWs suggestions can be summarized as interventions including (1) creating visual cards with scientific data on vaccine content and disease prevention and using them in counseling patients, (2) writing the vaccine components in a way understandable to ordinary people, (3) highlighting the national quality control and production in the vaccine box and labels, (4) conducting interviews with community opinion leaders, (5) training anti-vaccine HCWs with insufficient scientific knowledge and (6) reducing the tax of parents whose children are fully and punctually vaccinated.

Conclusions

The solution to vaccine rejection begins with the right approaches to vaccination during pregnancy. Prepared written and visual information notes should present the information as “vaccination acceptance” rather than “vaccination refusal”. Further studies on vaccine refusal rates should be carried out in various regions of the world so that region-specific actions are implemented to decrease the anti-vaxxer movement and to prevent an outbreak of infectious diseases.

Underpinning of the sharing knowledge about immunisation (SKAI) communication approach: A qualitative study using recorded observations

OBJECTIVE

To refine communication strategies to assist clinician conversations with vaccine hesitant and declining parents as part of the Sharing Knowledge About Immunisation (SKAI) package.

METHODS

We recorded and analysed consultations held in two Specialist Immunisation Clinics in tertiary hospitals in Australia between consenting clinicians and parents. We undertook content analysis that was both iterative and informed by the Calgary Cambridge Model of health communication and motivational interviewing.

RESULTS

We found common strengths and opportunities in clinician's communication styles. Strengths included: rapport building; communicating care for both the parent and child; exhibiting depth of vaccination-specific communication skill and content knowledge. Opportunities for strengthening communication practices included: eliciting parents' concerns to saturation early in the consultation; structuring the consultation to prioritise and address parents' concerns; recognising and responding to parents' motivation to vaccinate; effectively closing consultations.

CONCLUSION

This study has synthesised clinical communication strategies from expert vaccination communicators using well-established communication frameworks to advance a unique approach to the challenging task of addressing vaccine hesitancy and refusal.

PRACTICE IMPLICATIONS

The clinic observations helped us to create a structured consultation guide that can enhance and provide greater structure to a clinician's existing communication skills.

Intent to obtain pediatric influenza vaccine among mothers in four middle income countries

BACKGROUND

Despite a large burden of influenza in middle income countries, pediatric vaccination coverage remains low. The aims of this study were to (1) describe mothers' knowledge and attitudes about influenza illnesses and vaccination, and (2) identify characteristics associated with mothers' intent to vaccinate their child.

METHODS

From 2015 to 2017, infants 0-11 months old in Nicaragua, Philippines, Jordan, and Albania were enrolled from community settings and hospitals. Interviewers administered a questionnaire to their mothers. Mothers of infants aged 6-11 months rated their intention (small-to-moderate vs. large chance) to accept pediatric vaccination if it was offered at no-cost. The importance of knowledge, attitudes, and sociodemographic characteristics in predicting influenza vaccination intention was measured as the mean decrease in Gini index when that factor was excluded from 1000 decision trees in a random forest analysis.

RESULTS

In total, 1,308 mothers were enrolled from the community setting and 3,286 from the hospital setting. Prevalence of at least some knowledge of influenza illness ranged from 34% in Philippines to 88% in Albania (in the community sample), and between 23% in Philippines to 88% in Jordan (in the hospital sample). In the community sample, most mothers in Albania (69%) and Philippines (58%) would accept the influenza vaccine, and these proportions were higher in the hospital sample for all countries except Albania (48%) (P < 0.0001). Perceived vaccine safety (mean decrease in Gini index = 61) and effectiveness (55), and perceived knowledge of influenza vaccine (45) were the most important predictors of influenza vaccination intention in models that also included country and community versus hospital sample.

CONCLUSION

Intent to vaccinate infants aged 6-11 months in four middle income countries was tied primarily to knowledge of the vaccine and perceptions of vaccine safety and effectiveness. These findings were noted among mothers interviewed in the community and mothers of recently hospitalized infants.

Personal and social patterns predict influenza vaccination decision

BACKGROUND

Seasonal influenza vaccination coverage remains suboptimal in most developed countries, despite longstanding recommendations of public health organizations. The individual's decision regarding vaccination is located at the core of non-adherence. We analyzed large-scale data to identify personal and social behavioral patterns for influenza vaccination uptake, and develop a model to predict vaccination decision of individuals in an upcoming influenza season.

METHODS

We analyzed primary data from the electronic medical records of a retrospective cohort of 250,000 individuals between the years 2007 and 2017, collected from 137 clinics. Individuals were randomly sampled from the database of Maccabi Healthcare Services. Maccabi's clients are representative of the Israeli population, reflect all demographic, ethnic, and socioeconomic groups and levels. We used several machine-learning models to predict whether a patient would get vaccinated in the future. Models' performance was evaluated based on the area under the ROC curve.

RESULTS

The vaccination decision of an individual can be explained in two dimensions, Personal and social. The personal dimension is strongly shaped by a "default" behavior, such as vaccination timing in previous seasons and general health consumption, but can also be affected by temporal factors such as respiratory illness in the prior year. In the social dimension, a patient is more likely to become vaccinated in a given season if at least one member of his family also became vaccinated in the same season. Vaccination uptake was highly assertive with age, socioeconomic score, and geographic location. An XGBoost-based predictive model achieved an ROC-AUC score of 0.91 with accuracy and recall rates of 90% on the test set. Prediction relied mainly on the patient's individual and household vaccination status in the past, age, number of encounters with the healthcare system, number of prescribed medications, and indicators of chronic illnesses.

CONCLUSIONS

Our ability to make an excellent prediction of the patient's decision sets a major step toward personalized influenza vaccination campaigns, and will help shape the next generation of targeted vaccination efforts.

Vaccine rejection and hesitation in Turkey

In Turkey, primary care staffs have observed an increased rate of vaccination refusal in recent years. The aim of the present study was to determine the prevalence of vaccination refusal and hesitancy in Turkey, in addition to the demographic features and underlying reasons. The present descriptive cross-sectional study was conducted in İstanbul and Tekirdağ, two big Turkish cities that are exposed to widespread internal migration. To reflect Turkey’s demographic structure, 1004 participants were selected using cluster sampling based on birthplace, age, and level of education, from all individuals who attended family medicine outpatient clinics at Namık Kemal University and Şişli Hamidiye Etfal Training and Research Hospital. A face-to-face questionnaire method was used. Data show that this decline was mainly the result of the increasing rate of vaccine rejection and hesitation, for which the most important reason was found to be distrust of vaccine companies. It can be concluded that individuals who display vaccine refusal and hesitation are mostly born in the developed geographical regions of Turkey and have high income and educational levels. According to these results, we anticipate that vaccination rates may fall in Turkey in the coming years.

A scoping review examining the availability of dialogue-based resources to support healthcare providers engagement with vaccine hesitant individuals

BACKGROUND

There is growing attention around the need to improve the confidence and skills of healthcare providers to assist them in completing the complex task of communicating to vaccine hesitant parents and other individuals. While interventions have been developed and evaluated in a research setting, there is uncertainty regarding the public availability. This study aimed to examine the current landscape regarding the availability of online dialogue- based interventions which aim to support vaccination conversations.

METHODS

A scoping review was undertaken to identify and appraise the availability and accessibility of dialogue-based interventions. A dialogue-based intervention was defined as a strategy aiming to improve an individual's confidence and communication skills to engage with and respond to vaccine hesitant individuals. Two approaches were utilised to identify relevant interventions and resources. Firstly, the European Centre for Disease Prevention and Control Catalogue of Interventions was assessed to identify interventions that met the definition. Secondarily, a Google search (in English only) was conducted using key words, that reflected the strategy that healthcare providers may use to identify resources.

RESULTS

We identified a total of 31 dialogue-based interventions, of which 29 were reviewed. The interventions were all text based and instructional in nature. Twenty-two were suitable for healthcare providers, as well as non-clinical immunisation spokespersons to use. Of issue, was that in many instances it was common to find the resource located on the fifth to tenth page of search entries, and usually disguised under seemingly non-descript and nonspecific titles. Lastly, not all resources were available for free and not all could be accessed directly from the site.

CONCLUSIONS

Findings suggest that while there have been numerous interventions developed to support healthcare providers to communicate with vaccine hesitant parents/individuals, there are fundamental issues with accessing the materials in a timely and convenient way. Having a central repository or website (which links to the interventions) would not only assistant healthcare providers to have an improved comprehension of the different interventions available but also would theoretically increase the utilisation by providers.

Socioeconomic status differences in parental immunization attitudes and child immunization in Canada: Findings from the 2013 Childhood National Immunization Coverage Survey (CNICS)

Childhood vaccination efforts in Canada have been negatively impacted by parents' vaccine hesitancy based on their knowledge, attitudes, and beliefs (KAB) about vaccinations. Less understood is the extent to which child vaccination receipt and KAB vary by parents' socioeconomic status (SES). Analyzing different age groups of children and vaccinations, we examine the extent to which (a) family SES (parent education, household income) is a determinant of Canadian parents' vaccination KAB and child vaccination receipt, and (b) whether SES was indirectly associated with receipt via KAB. In 2017, we analyzed 2013 Childhood National Immunization Coverage Survey (CNICS) data. We estimated models for parental KAB and child vaccination receipt for measles, mumps, and rubella (MMR) at age 2 (n = 3620); diphtheria, pertussis, and tetanus (DPT) at age 7 (n = 3465); and human papillomavirus (HPV) at ages 12-14 (n = 5213 females). SES is inconsistently associated with KAB and vaccine receipt across the three age groups. SES differences in KAB mostly center on vaccine-specific side effect and safety concerns, with lower education and income levels associated with higher odds of being concerned. Non-receipt of minimum age-specific vaccination dosages was associated with concerns about vaccine effectiveness (DPT, HPV) and side effects (MMR, HPV) and lower perceived importance of immunizing a child (MMR, HPV). KAB mediation was mostly limited to SES patterns in MMR. We discuss the implications of these findings for designing general and population-specific vaccination education strategies and future studies of KAB and undervaccination.

Immunization in Vietnam

Since the Expanded Program on Immunization was proposed by the World Health Organization in 1981, it has been promptly adopted by Vietnam as one of the country's national priority programs. In 1986, Vietnam achieved some remarkable goals, including polio-free status and the elimination of neonatal tetanus. At the same time, however, barriers and difficulties have also emerged. This article aims to provide an overview of both achievements and barriers to the implementation of the program and proposes some solutions.

Vaccine non-receipt and refusal in Ethiopia: The expanded program on immunization coverage survey, 2012

INTRODUCTION

Rates of full childhood immunization in Ethiopia are well below the WHO global goal of 90% coverage by 2020. This study explores associations between sociodemographic characteristics and healthcare services utilization with experiences of not receiving a vaccine in Ethiopia.

METHODS

This analysis uses data from Ethiopia's 2012 Expanded Program on Immunization Coverage Survey. The relationships between explanatory variables, including sociodemographic and healthcare utilization factors, and various reasons a child was not vaccinated were assessed with Rao-Scott chi-square tests. Multivariable logistic regression analyses examined significant predictors of these experiences.

RESULTS

The sample includes the caregivers of 2,722 children. Experiences of not receiving a vaccine were characterized overall and by type of experience: whether a caregiver ever refused vaccination for their child (2.9%), ever decided to not take their child to a health center for vaccination (3.6%), and ever went to a health facility for vaccination but child was not vaccinated (12.0%). Region of residence, possession of a vaccination card, and the setting of the child's last routine vaccination were predictors of not receiving a vaccine. Caregivers reported negative perceptions of vaccines were among their reasons for refusing a vaccine or declining to take their child to a health facility for vaccination.

CONCLUSION

Prior experiences with health facilities, such as where a child received their last routine vaccine, play a key role in future vaccination. Vaccine receipt at an outreach event is associated with not bringing a child to a health facility for vaccination, which may indicate an unwillingness to visit or difficulty accessing health centers. Further, negative perceptions of vaccines may result in vaccine refusal or delay. Findings of this study provide public health officials with a better understanding of factors related to vaccination experiences and can inform development of interventions that will improve childhood vaccination rates in Ethiopia.

Evaluation of Childhood Vaccine Refusal and Hesitancy Intentions in Turkey

OBJECTIVE

To assess the factors affecting parental childhood vaccine refusal and hesitancy (CVRH) intentions in Turkey.

METHODS

A total of 33 children's parents who were referred to two different child health care clinics because of CVRH and 99 controls were enrolled into this study from November through December 2017. The socio-demographic characteristics and perceptions of the parents who refused at least one vaccine for their child/children were compared with controls.

RESULTS

The monthly household income was significantly lower in CVRH group than control group. Refusal of the heel stick, refusal of hearing test, not using baby car seat, irregular use of vitamin D and iron prophylaxis, using alterative/complementary medicine, distrust in vaccines were the parameters which were found significantly higher in refused vaccine group than in control group. The beliefs "It may be dangerous for children" and "Distrust to the vaccines" were the most determined factors with a ratio of 51.5% in CVRH group.

CONCLUSIONS

This is the first study conducted to investigate the social-demographic characteristics and perception of parental CVRH in Turkey. The beliefs "It may be dangerous for the children" and "Distrust the vaccines" were the most determined factors which may affect CVRH. Some child health protective strategies were less undertaken in CVRH group than in controls; including heel stick test, hearing test, using baby car seat and using of Vitamin D and iron prophylaxis. The parents who have CVRH intentions tend to behave irresponsibly in care of their children.