Describing the evidence-base for research engagement by health care providers and health care organisations: a scoping review.

BACKGROUND: Having a research-engaged health and medical workforce is associated with improvements in clinical outcomes for patients. As such, there has been significant government investment internationally to support health care organisations and services to increase staff engagement with research. OBJECTIVES: This scoping review sought to provide an overview of the literature describing strategies employed to increase research engagement by health care providers and organisations, and to undertake a qualitative analysis to generate a list of research engagement strategies. METHODS: A scoping review using systematic search strategies was undertaken to locate peer-review publications and grey literature related to research engagement by health care providers and organisations. Research engagement was defined as a 'deliberate set of intellectual and practical activities undertaken by health care staff and organisations to conduct research'. A database search of electronic records was performed with no limit on publication date. Publications were included regardless of study type (excluding systematic reviews) and categorised as either databased (presenting data or new analysis of existing data) and non-databased (no new data or analyses). Databased publications were further classified according to study type, study design and setting. A qualitative synthesis using a Framework Approach was undertaken with all studies that described a strategy to improve research engagement. RESULTS: A total of 152 publications were included in this study with 54% categorised as non-databased. Of the databased articles, the majority (72%) were descriptive studies describing prevalence of correlates of research engagement, 17 (25%) described intervention studies where only two were controlled studies. The following research engagement strategies were identified: i) dual skilled team/staff, ii) resources or physical infrastructure, iii) incentives, iv) leadership support of research, v) education/training, vi) networks, vii) forming partnerships or collaborations and viii) overall leadership structure of entity. CONCLUSIONS: The literature on research engagement is primarily opinion-based and descriptive in nature. To provide the evidence needed to inform strategies, this needs to progress beyond descriptive to more rigorous well-designed intervention research.

Meaningful coproduction with clinicians: establishing a practice-based research network with physiotherapists in regional Australia.

BACKGROUND: The disconnect between research and clinical practice leads to research evidence that is often not useful for clinical practice. Practice-based research networks are collaborations between researchers and clinicians aimed at coproducing more useful research. Such networks are rare in the physiotherapy field. We aimed to describe (i) clinicians' motivations behind, and enablers to, participating in a network, (ii) the process of network establishment and (iii) research priorities for a practice-based network of physiotherapists in the Hunter Region of New South Wales (NSW), Australia that supports research coproduction. METHODS: We describe the methods and outcomes of the three steps we used to establish the network. Step 1 involved consultation with local opinion leaders and a formative evaluation to understand clinicians' motivations behind, and enablers to, participating in a network. Step 2 involved establishment activities to generate a founding membership group and codesign a governance model. Step 3 involved mapping clinical problems through a workshop guided by systems thinking theory with local stakeholders and prioritizing research areas. RESULTS: Through formative evaluation focus groups, we generated five key motivating themes and three key enablers for physiotherapists' involvement in the network. Establishment activities led to a founding membership group (n = 29, 67% from private practice clinics), a network vision and mission statement, and a joint governance group (9/13 [70%] are private practice clinicians). Our problem-mapping and prioritization process led to three clinically relevant priority research areas with the potential for significant change in practice and patient outcomes. CONCLUSIONS: Clinicians are motivated to break down traditional siloed research generation and collaborate with researchers to solve a wide array of issues with the delivery of care. Practice-based research networks have promise for both researchers and clinicians in the common goal of improving patient outcomes.

Ezidi voices: The communication of COVID-19 information amongst a refugee community in rural Australia- a qualitative study.

BACKGROUND: There is growing evidence that government health information related to COVID-19 has failed to adequately reach culturally and linguistically diverse (CALD) populations in Australia. Refugees are a unique sub-set of the CALD communities and are subject to numerous barriers preventing adequate health care, both pre- and post-migration. The barriers are accentuated during emergencies, such as a pandemic, as a result of an intersection of various social and economic inequalities. The recently resettled Ezidi refugee community in a regional area of Australia is an example of a community sitting at the intersection of various inequities and thus at greater risk from COVID-19. The purpose of this study is to describe the experiences of the Ezidi in a regional area with COVID-19 information and how this has been communicated to and shared within this group; what barriers the community may experience in accessing COVID-19 information; and how the government-led COVID-19 information communication could be improved. METHODS: This qualitative study was designed to explore the perceptions and views of the Ezidi and service providers regarding COVID-19 messaging. Multicultural and Refugee Health staff facilitated interviews with four local service providers and ten Ezidi community members, including seven influential leaders. Thematic analysis was employed across individual, pair and group data analysis. Similar categories were grouped into themes. RESULTS: The main findings of the study are: the refugee experience influences the communication of COVID-19 messages; cultural, social and gender norms influence responses to COVID-19; trusted individuals and service providers are key in communities' uptake of COVID-19 messages; currently available governmental COVID-19 information resources and sharing strategies were found unhelpful and inappropriate; COVID-19 communiqués and message delivery for this regional minority refugee community can be improved. CONCLUSION: The recently resettled Ezidi community, and likely other similar communities, would benefit from tailored engagement by government organisations, as well as settlement services to improve the communication of COVID-19 health information and reduce related inequities.

Factors contributing to the sharing of COVID-19 health information amongst refugee communities in a regional area of Australia: a qualitative study.

BACKGROUND: The COVID-19 pandemic has had a disproportionate impact on culturally and linguistically diverse (CALD) groups worldwide. Newly emerging CALD populations formed by recently arrived refugees are predisposed to even greater health disadvantages due to complexities of the refugee experience. The aim of this study was to explore how culture, refugee experiences and existing relationships shaped what COVID-19 messages were listened to and shared during the early-mid phases of the pandemic. The work focused on three newly emerging refugee groups in the Hunter New England region, Australia: Afghan, Congolese and Syrian communities. METHODS: Qualitative, semi-structured interviews were conducted to explore the experiences and stories of 15 adult community members, nine influential members and six service providers. All community members arrived in Australia on or after January 2014. Interpreter-assisted interviews were conducted with small groups or individuals, audio-recorded and transcribed verbatim in English. Three levels of thematic data analysis were employed to uncover the important issues and experiences of the participants. RESULTS: Three key themes and several subthemes were identified. The themes were: 1) Experience as a refugee uniquely influences COVID-19 message communication; 2) Refugee groups use diverse practices when accessing and sharing COVID-19 messages; and 3) Official government messages could be improved by listening and tailoring to community needs. CONCLUSIONS: Effective health messaging relies on reaching communities in a culturally acceptable and meaningful way. Official COVID-19 messages can be tailored to engage newly emerging communities by improving the quality of the content, delivery and format whilst working collaboratively with communities and trusted service providers. Further mutual research is needed to understand emerging communities' viewpoints. The use of culturally informed approaches is recommended.

Physiotherapists' opinions, barriers, and enablers to providing evidence-based care: a mixed-methods study.

BACKGROUND: Physiotherapists deliver evidence-based guideline recommended treatments only half of the time to patients with musculoskeletal conditions. Physiotherapists' behaviour in clinical practice are influenced by many cognitive, social, and environmental factors including time and financial pressures. Many initiatives aimed at improving physiotherapists' uptake of evidence-based care have failed to appreciate the context involved in clinical decisions and clinical practice. Therefore, we aimed to describe: i) opinions toward evidence; ii) how evidence is accessed; iii) factors influencing evidence access; iv) factors influencing evidence application, for physiotherapists working in regional areas. METHODS: We used a mixed-methods study with online survey and focus groups. We included registered physiotherapists in the survey and physiotherapists practising in regional New South Wales in the focus groups. Quantitative and qualitative data were used to inform all research objectives. We used eight domains of the Transtheoretical Domains Framework to design survey questions. We analysed quantitative and qualitative data in parallel, then integrated both sources through by developing a matrix while considering the Transtheoretical Domains Framework domains to generate themes. RESULTS: Fifty-seven physiotherapists participated in the study (survey only n = 41; focus group only n = 8; both survey and focus group n = 8). Participants reported that evidence was important, but they also considered patient expectations, colleagues' treatment choices, and business demands in clinical decision making. Physiotherapists reported they access evidence on average 30 minutes or less per week. Competing demands like business administration tasks are barriers to accessing evidence. Participants reported that patient expectations were a major barrier to applying evidence in practice. Environmental and systemic factors, like funding structures or incentives for evidence-based care, and social factors, like lacking or having a culture of accountability and mentorship, were reported as both barriers and enablers to evidence application. CONCLUSIONS: This study provides context to physiotherapists' opinion, access, and application of evidence in clinical practice. Physiotherapists' provision of evidence-based care may be improved by enhancing structural support from workplaces to access and apply evidence and exploring discrepancies between physiotherapists' perceptions of patient expectations and actual patient expectations.

'Immunisation, I haven't had a problem, but once again the transport, making an appointment, the time that you waste and all of those things are an issue'-Understanding childhood under-immunisation in Mid North Coast New South Wales, Australia.

OBJECTIVES: This study aimed to understand the reasons for childhood under-immunisation in Kempsey, New South Wales, among First Nations and non-First Nations families, and potential strategies to improve coverage. DESIGN: The World Health Organization's Tailoring Immunization Programmes guide was employed. Tailoring Immunization Programmes uses social science, qualitative research methods and community participation and is underpinned by the Capabilities Opportunities Motivations-Behaviors (COM-B) theoretical model of behaviour change. A cultural lens was applied throughout the study design. Using a thematic analysis, factors found to influence childhood under-immunisation were loosely mapped against COM-B framework. SETTING: Face-to-face interviews and focus groups conducted in locations and at times convenient to participants were audio-recorded and transcribed verbatim. PARTICIPANTS: Fifty-six participants (25 First Nations and 13 non-First Nations mothers and grandmothers, and 18 health service providers) took part in the study (July-October 2019). RESULTS: Four themes were identified: (a) parents are supportive of immunisation and effective reminders would make it easier to prioritise it (b) services could be more accessible for families (c) addressing workforce shortages could improve access to immunisation services and (d) addressing entrenched racism in the community will help build cultural safety in health services. While parents in Kempsey were supportive of immunisation, resourceful and resilient, many struggled to overcome entrenched structural and cultural barriers to accessing services. This was particularly difficult for First Nations, socially disadvantaged and single mums. CONCLUSIONS: Public health services can provide more support to those mothers and grandmothers who need it most, to ensure they are able to access immunisation services without delay.

The Impact of Public Health Restrictions in Residential Aged Care on Residents, Families, and Staff During COVID-19: Getting the Balance Right.

Outbreaks of COVID-19 in a small number of aged care facilities in Australia had devastating mortality ratios. Strict infection control measures were implemented with little time to adapt. This study explored the views and experiences of residents, families, and care providers about the preparation for COVID-19 and identified areas for improvement. Twenty-one individual interviews were conducted. Using interpretative phenomenological analysis, we found rapid changes to visiting and activities, with physical and emotional impact. Some participants coped using personal resources. Family and residents valued the empathy and quality care provided, despite the overburdened workforce. Good leadership supported implementation of public health advice, but the severity of measures should be proportionate to local risk. Better pandemic planning that includes clear responsibilities, training, and evaluation is important. Consultation with residents, family, and health workers throughout a pandemic will help identify those most at risk of social isolation and physical decline and develop strategies to minimize their impact. The rights and welfare of residents must be respected at all times.

Examining Australian public perceptions and behaviors towards a future COVID-19 vaccine.

BACKGROUND: As immunisation program launches have previously demonstrated, it is essential that careful planning occurs now to ensure the readiness of the public for a COVID-19 vaccine. As part of that process, this study aimed to understand the public perceptions regarding a future COVID-19 vaccine in Australia. METHODS: A national cross-sectional online survey of 1420 Australian adults (18 years and older) was undertaken between 18 and 24 March 2020. The statistical analysis of the data included univariate and multivariable logistic regression model analysis. RESULTS: Respondents generally held positive views towards vaccination. Eighty percent (n = 1143) agreed with the statement that getting myself vaccinated for COVID-19 would be a good way to protect myself against infection. Females (n = 614, 83%) were more likely to agree with the statement than males (n = 529, 78%) (aOR = 1.4 (95% CI: 1.1-1.8); P = 0.03), while 91% of those aged 70 years and above agreed compared to 76% of 18-29-year-olds (aOR = 2.3 (95% CI:1.2-4.1); P = 0.008). Agreement was also higher for those with a self-reported chronic disease (aOR = 1.4 (95% CI: 1.1-2.0); P = 0.04) and among those who held private health insurance (aOR = 1.7 (95% CI: 1.3-2.3); P < 0.001). Beyond individual perceptions, 78% stated that their decision to vaccinate would be supported by family and friends. CONCLUSION: This study presents an early indication of public perceptions towards a future COVID-19 vaccine and represents a starting point for mapping vaccine perceptions. To support an effective launch of these new vaccines, governments need to use this time to understand the communities concerns and to identify the strategies that will support engagement.

Adaptation of public health initiatives: expert views on current guidance and opportunities to advance their application and benefit.

While there is some guidance to support the adaptation of evidence-based public health interventions, little is known about adaptation in practice and how to best support public health practitioners in its operationalization. This qualitative study was undertaken with researchers, methodologists, policy makers and practitioners representing public health expert organizations and universities internationally to explore their views on available adaptation frameworks, elicit potential improvements to such guidance, and identify opportunities to improve implementation of public health initiatives. Participants attended a face to face workshop in Newcastle, Australia in October 2018 where World Café and focus group discussions using Appreciative Inquiry were undertaken. A number of limitations with current guidance were reported, including a lack of detail on 'how' to adapt, limited information on adaptation of implementation strategies and a number of structural issues related to the wording and ordering of elements within frameworks. A number of opportunities to advance the field was identified. Finally, a list of overarching principles that could be applied together with existing frameworks was generated and suggested to provide a practical way of supporting adaptation decisions in practice.

Implementation of continuous free play schedules in Australian childcare services: A cross-sectional study.

ISSUE ADDRESSED: Modifying the scheduling of physical activity opportunities to provide children with more frequent opportunities for outdoor free play has been demonstrated to increase child physical activity while in care. The primary aim of this study was to describe the implementation of continuous free play schedules to allow children to access outdoor play areas, consistent with sector guidelines in a national sample of Australian childcare services. Secondary aims were to investigate the associations between the implementation of such schedules and service characteristics, and assess the perceived barriers and enablers to implementation. METHODS: A cross-sectional study was undertaken with a random sample of 326 centre-based childcare services located across Australia. Childcare service characteristics, continuous free play scheduling and perceived barriers and enablers to implementation were assessed via a survey administered to service managers online or via telephone. RESULTS: A total of 203 service managers (62%) reported implementing a continuous free play schedule, for three periods of 126 minutes per period, each day on average. Service type (long day care services), size (services with higher numbers of child enrolments [≥80 children]) and socio-economic area (services located in lower socio-economic areas) were associated with the implementation of a continuous free play schedule. The most prevalent barriers to implementation included insufficient staff to ensure adequate supervision of children (69%) and service layout being unsuitable (65%), while the most prevalent enablers included advice on how to overcome staffing or supervision issues (89%) and to re-orientate the service layout (54%). CONCLUSIONS: There is scope to support the implementation of continuous free play schedules consistent with childcare sector guidelines. SO WHAT?: Future intervention research that targets the reported barriers and enablers to implementation is needed.

Optimisation: defining and exploring a concept to enhance the impact of public health initiatives.

BACKGROUND: Repeated, data-driven optimisation processes have been applied in many fields to rapidly transform the performance of products, processes and interventions. While such processes may similarly be employed to enhance the impact of public health initiatives, optimisation has not been defined in the context of public health and there has been little exploration of its key concepts. METHODS: We used a modified, three-round Delphi study with an international group of researchers, public health policy-makers and practitioners to (1) generate a consensus-based definition of optimisation in the context of public health and (2i) describe key considerations for optimisation in that context. A pre-workshop literature review and elicitation of participant views regarding optimisation in public health (round 1) were followed by a daylong workshop and facilitated face-to-face group discussions to refine the definition and generate key considerations (round 2); finally, post-workshop discussions were undertaken to refine and finalise the findings (round 3). A thematic analysis was performed at each round. Study findings reflect an iterative consultation process with study participants. RESULTS: Thirty of 33 invited individuals (91%) participated in the study. Participants reached consensus on the following definition of optimisation in public health: "A deliberate, iterative and data-driven process to improve a health intervention and/or its implementation to meet stakeholder-defined public health impacts within resource constraints". A range of optimisation considerations were explored. Optimisation was considered most suitable when existing public health initiatives are not sufficiently effective, meaningful improvements from an optimisation process are anticipated, quality data to assess impacts are routinely available, and there are stable and ongoing resources to support it. Participants believed optimisation could be applied to improve the impacts of an intervention, an implementation strategy or both, on outcomes valued by stakeholders or end users. While optimisation processes were thought to be facilitated by an understanding of the mechanisms of an intervention or implementation strategy, no agreement was reached regarding the best approach to inform decisions about modifications to improve impact. CONCLUSIONS: The study findings provide a strong basis for future research to explore the potential impact of optimisation in the field of public health.

"COVID-19 - A Perfect Storm": A Qualitative Exploration of Residential Care Facility Managers Perspectives on the Psychosocial Impacts of COVID-19.

Growing evidence highlights the negative impact of managing the COVID-19 pandemic on the wellbeing of the healthcare workforce, including in the aged care sector. We undertook a qualitative study during the pandemic's third year to explore the psychosocial impacts on nine managers of residential care facilities (RCFs) across metropolitan and rural New South Wales, the largest state in Australia. Four themes were identified: (1) Increased pressure on maintaining aged care services, (2) Increased responsibility on RCF managers, (3) Psychosocial impacts due to accumulating pressures, and (4) Experience of beneficial supports. COVID-19 compounded pre-pandemic sector challenges and added new stressors. While resilient and resourceful, RCF managers experienced workplace stress and burnout, which may affect quality of resident care and impact on staff retention. There is a need for more investment to effectively support staff, and research to identify optimal psychosocial and management supports.

Implementing recommended COVID-19 public health measures in the era of living with COVID-19: Experiences of residential aged care facility managers in New South Wales, Australia.

OBJECTIVES: To understand residential aged care facility (the facility) managers' perspectives on implementing public health measures (the measures) in their facilities in terms of barriers, facilitators and suggestions for improvement, after three years of the COVID-19 pandemic. METHODS: Nine managers of the facilities without an active COVID-19 outbreak across New South Wales, Australia, representing metropolitan and rural locations, diverse facility size and star quality rating were interviewed (April-June 2023) and data qualitatively analysed. RESULTS: Broader policy context, the need to balance the measures with resident well-being, facility-built infrastructure and mask fatigue were reported as barriers to implementation. Workplace policies, cultural embedding and local innovations were reported as facilitators. Suggested strategies included recommending the measures consistent with temporal COVID-19 risk; government agencies improving communication about the measures; mandatory staff vaccination; and simplified reporting requirements. CONCLUSIONS: We recommend that relevant government agencies develop a single source of formalised, endorsed, up-to-date advice for the sector-specific COVID-19 information and communications; streamline outbreak notification and reporting requirements; and improve consultation with the sector.

COVID-19 vaccination acceptance among older adults: A qualitative study in New South Wales, Australia.

Objectives: The COVID-19 pandemic has had a severe impact on people across the world, particularly older adults who have a higher risk of death and health complications. We aimed to explore older adults' intention towards COVID-19 vaccination and factors that influenced their motivation to get vaccinated. Study design: A qualitative study was conducted in New South Wales, Australia (April 2021), involving interviews with older adults (aged 70 years and older). Methods: In-depth interviews were carried out with 14 older adults on their perceptions around COVID-19 vaccination. The COVID-19 vaccination program had just commenced at the time of data collection. We thematically analysed interviews and organised the themes within the Behavioural and Social Drivers of Vaccination (BeSD) Framework. Results: We found that most participants were accepting of COVID-19 vaccination. Participants' motivation to get vaccinated was influenced by the way they thought and felt about COVID-19 disease and vaccination (including perceptions of vaccine safety, effectiveness, benefits, COVID-19 disease risk, and vaccine brand preferences) and social influences (including healthcare provider recommendation, and influential others). The uptake of COVID-19 vaccination was also mediated by practical issues such as access and affordability. Conclusions: Efforts to increase COVID-19 vaccination acceptance in this population should focus on highlighting the benefits of vaccination. Support should be given to immunisation providers to enhance efforts to discuss and recommend vaccination to this high-risk group.

Understanding the factors that influence communication about COVID-19 vaccines with patients: Perspectives of Australian immunisation providers.

Background: COVID-19 immunisation providers have been at the forefront of the pandemic, and their ability to communicate effectively with patients is key to encouraging COVID-19 vaccine acceptance and uptake. This study explored providers' perspectives on the factors influencing communication with patients about COVID-19 vaccines. Methods: We used an explanatory-sequential mixed-methods approach to conduct the study between December 2021 and March 2022. Phase I involved a cross-sectional survey with immunisation providers in New South Wales (n = 341; 189 general practitioners, 118 nurses and 34 pharmacists), followed by Phase II: semi-structured, in-depth qualitative interviews (n = 19; 10 nurses, 9 pharmacists). We generated descriptive results for the survey. We analysed the qualitative data thematically using an inductive approach. Results: Almost half of survey participants reported communicating often with people who were hesitant about COVID-19 vaccines (49 %; 166/341), however, 21 % (71/341) reported inadequate time to address concerns during consultations. Interview participants reported communication challenges, including time constraints, difficulties addressing and eliciting patient concerns, and keeping up to date with changing information. Conversely, interview participants reported that easy access to government information resources, time to learn about COVID-19 vaccines proactively, knowing about and being able to use tailored strategies to support Aboriginal and Torres Strait Islander and CALD patients were helpful when communicating with patients. Conclusions: Immunisation providers play an important role in patient vaccine acceptance and uptake. Our findings indicate that whilst providers were largely confident in their interactions with patients, further communication support would strengthen providers' skills in communicating with patients who have questions and concerns about COVID-19 vaccines.

A qualitative study on COVID-19 pandemic impacts on parental attitudes and intentions for routine adolescent vaccinations: The role of trust.

INTRODUCTION: The COVID-19 pandemic has contributed to declines in routine childhood and adolescent vaccination coverage globally. While the declines in Australia have been less, they are a concern, given steady increases in coverage prior to the pandemic. Given limited evidence on how the experiences of parents during the pandemic affected their attitudes about and intentions towards adolescent vaccinations, with this study we aimed to explore these. METHODS: This was a qualitative study. We invited parents of adolescents eligible for school-based vaccinations in 2021 from metropolitan, regional and rural areas of New South Wales and Victoria (the most affected States) and South Australia (less affected) to half hour-long online semi-structured interviews. We analysed data thematically and applied a conceptual model of trust in vaccination. RESULTS: In July 2022 we interviewed 15 accepting, 4 hesitant and two parents who refused adolescent vaccinations. We identified three themes: 1. Pandemic impacting on professional and personal lives and routine immunisations; 2. Pandemic strengthening preexisting vaccine hesitancy, with perceived lack of clarity in governmental information about vaccination and stigma around non-vaccinating as contributing factors; 3. Pandemic raising awareness of the benefits of COVID-19 and routine vaccinations, with communication campaigns and one's trusted doctor's vaccination recommendations as contributing factors. CONCLUSIONS: For some parents, experiences of poor system readiness and growing distrust towards health and vaccination systems strengthened their pre-existing vaccine hesitancy. We offer recommendations on how trust in the health system and immunisation can be optimised post-pandemic to increase uptake of routine vaccines. These include improving access to vaccination services and clear, timely information about vaccines; supporting immunisation providers in their immunisation consultations; working alongside communities, and building capacity of vaccine champions.

What does high value care for musculoskeletal conditions mean and how do you apply it in practice? A consensus statement from a research network of physiotherapists in New South Wales, Australia.

OBJECTIVES: To develop a physiotherapist-led consensus statement on the definition and provision of high-value care for people with musculoskeletal conditions. DESIGN: We performed a three-stage study using Research And Development/University of California Los Angeles Appropriateness Method methodology. We reviewed evidence about current definitions through a rapid literature review and then performed a survey and interviews with network members to gather consensus. Consensus was finalised in a face-to-face meeting. SETTING: Australian primary care. PARTICIPANTS: Registered physiotherapists who are members of a practice-based research network (n=31). RESULTS: The rapid review revealed two definitions, four domains of high value care and seven themes of high-quality care. Online survey responses (n=26) and interviews (n=9) generated two additional high-quality care themes, a definition of low-value care, and 21 statements on the application of high value care. Consensus was reached for three working definitions (high value, high-quality and low value care), a final model of four high value care domains (high-quality care, patient values, cost-effectiveness, reducing waste), nine high-quality care themes and 15 statements on application. CONCLUSION: High value care for musculoskeletal conditions delivers most value for the patient, and the clinical benefits outweigh the costs to the individual or system providing the care. High-quality care is evidence based, effective and safe care that is patient-centred, consistent, accountable, timely, equitable and allows easy interaction with healthcare providers and healthcare systems.

"I'm scared that if I have the vaccine, it's going to make my lung condition worse, not better." COVID-19 vaccine acceptance in adults with underlying health conditions - A qualitative investigation.

Background: Sustained uptake of COVID-19 vaccines, including booster doses, will continue to be key to minimising morbidity and mortality caused by COVID-19. Because hesitancy can affect people's motivation to get vaccinated, understanding and addressing factors influencing acceptance is critical to achieving high uptake. This is especially the case for adults with underlying health conditions, who are at increased risk of severe illness from COVID-19. The aim of this study was to investigate barriers and facilitators of COVID-19 vaccine acceptance in adults with underlying health conditions during the initial rollout of COVID-19 vaccines in Australia. Methods: We conducted semi-structured, qualitative interviews with 15 adults with underlying health conditions in New South Wales (NSW) in April 2021, focusing on their previous vaccination experiences and feelings about COVID-19 vaccination. We categorised participants as accepting, hesitant or refusing. We analysed interviews thematically, informed by the World Health Organization (WHO) Behavioural and Social Drivers of Vaccination framework. Results: Most (12/15) participants were hesitant about COVID-19 vaccination. Barriers to COVID-19 vaccine acceptance included concerns about vaccine safety and effectiveness; heightened perceptions of risk regarding the vaccines; low perceptions of COVID-19 risk; and negative social influences. Facilitators included perceived benefits of vaccination and positive social influences. Conclusions: For some adults with underlying health conditions, perceptions of heightened vulnerability to COVID-19 vaccine side effects contributed to vaccine hesitancy during the initial rollout of COVID-19 vaccines. We recommend supporting GPs and specialists to proactively reach out and recommend COVID-19 vaccination to this population; encouraging chronic disease organisations to act as trusted advocates of COVID-19 vaccination; and actively communicating evolving knowledge about vaccine safety.

Structural and social inequities contribute to pockets of low childhood immunisation in New South Wales, Australia.

Introduction: Childhood immunisation is a safe and effective way to protect children and communities from serious diseases. In Australia childhood immunisation is generally well accepted with high coverage rates however pockets of low coverage exist. Authors conducted five previous studies in New South Wales which found socio-economic disadvantage, gender inequity, health service access barriers and under-utilisation of immunisation data, rather than ideological opposition, contributed to children's incomplete vaccination. Material and Methods: Common findings across those five studies were identified. Additional literature was reviewed using a number of lenses, underpinned by a social determinants of health framework. Results: The lensed approach allowed further exploration of the impact of financial stress, poor mental health, drug and alcohol problems, domestic violence, assumed gender roles, lack of culturally acceptable health care for Indigenous families, geography and changes to immunisation policies on families and how this may have contributed to pockets of low immunisation coverage. Social and structural inequities were revealed. These often contributed to conflicting priorities that meant children's immunisations fell behind. Discussion: Strategies to address inequities may include reorientation of existing community based child health services to include flexible options such as drop in clinics, outreach services, home visiting and ensuring Indigenous families have access to culturally safe and acceptable services. Assistance with transport would further improve access to services. Better use of immunisation data can aid in the identification of pockets of low coverage and monitor and evaluate service effectiveness. Conclusions: Greater awareness of social and structural barriers and their impact on families can inform the design of tailored strategies that address the needs of disadvantaged children and families. Without efforts to overcome the inequities that contribute to low immunisation coverage, the status quo persists, leaving children and communities at risk of vaccine preventable diseases.