Perceptions of yellow fever emergency mass vaccinations among vulnerable groups in Uganda: A qualitative study.

BACKGROUND: Yellow fever (YF), a mosquito-borne viral hemorrhagic fever, is endemic in Uganda and causes frequent outbreaks. A total of 1.6 million people were vaccinated during emergency mass immunization campaigns in 2011 and 2016. This study explored local perceptions of YF emergency mass immunization among vulnerable groups to inform future vaccination campaigns. METHODOLOGY: In this qualitative study, we conducted 43 semi-structured interviews, 4 focus group discussions, and 10 expert interviews with 76 participants. Data were collected in six affected districts with emergency mass vaccination. We included vulnerable groups (people ≥ 65 years and pregnant women) who are typically excluded from YF vaccination except during mass immunization. Data analysis was conducted using grounded theory. Inductive coding was utilized, progressing through open, axial, and selective coding. PRINCIPAL FINDINGS: Participants relied on community sources for information about the YF mass vaccination. Information was disseminated door-to-door, in community spaces, during religious gatherings, and on the radio. However, most respondents had no knowledge of the vaccine, and it was unclear to them whether a booster dose was required. In addition, the simultaneous presidential election during the mass vaccination campaign led to suspicion and resistance to vaccination. The lack of reliable and trustworthy information and the politicization of vaccination campaigns reinforced mistrust of YF vaccines. CONCLUSIONS/SIGNIFICANCE: People in remote areas affected by YF outbreaks rely on community sources of information. We therefore recommend improving health education, communication, and engagement through respected and trusted community members. Vaccination campaigns can never be seen as detached from political systems and power relations.

Vaccine hesitancy among physicians: a qualitative study with general practitioners and paediatricians in Austria and Germany.

OBJECTIVE: This study aims to understand reasons for vaccine hesitancy (VH) among general practioners (GPs) and paediatricians. We aim to analyse how and when the healthcare workers (HCWs) developed vaccine-hesitant views and how they transfer these to patients. DESIGN AND SETTING: Semistructured interviews with vaccine-hesitant GPs and paediatricians were conducted in Austria and Germany using an explorative qualitative research design. PARTICIPANTS: We contacted 41 physicians through letters and emails and 10 agreed to participate, five were male and five female. DATA COLLECTION AND ANALYSIS: Ten interviews were recorded, transcribed verbatim and anonymised. The material was analysed inductively following a grounded theory approach with open coding using the software atlas.ti. RESULTS: Key themes that were identified were education and career path, understanding of medicine and medical profession, experiences with vaccines, doctor-patient interactions and continuous education activities and the link to VH. GPs and paediatricians' vaccine-hesitant attitudes developed during their medical training and, in particular, during extracurricular training in homeopathy, which most of the participants completed. Most participants work in private practices rather than with contracts with social insurance because they are not satisfied with the health system. Furthermore, they are critical of biomedicine. Most of the interview partners do not consider themselves antivaccination, but are sceptical towards vaccines and especially point out the side effects. Most do not vaccinate in their practices and some do only occasionally. Their vaccine-hesitant views are often fostered through respective online communities of vaccine-hesitant HCWs. CONCLUSIONS: More studies on a connection between complementary medicine and vaccine-hesitant views of HCWs are needed. Education about vaccines and infectious diseases among healthworkers must increase especially tailored towards the use of internet and social media. Physicians should be made aware that through time and empathy towards their patients they could have a positive impact on undecided patients and parents regarding vaccine decisions.

Locating vaccine uptake and public participation in Ukraine: An exploratory qualitative study on attitudes and barriers to early childhood vaccination.

A growing body of literature on vaccine hesitancy considers context and the intersecting factors affecting vaccine uptake. This study attempts to add focus to the conversation of vaccines in Ukraine by exploring how vaccines are perceived and how local stakeholders envision solutions to the problems surrounding vaccine uptake. Twenty-five in-depth interviews were carried out among parents of children under 6 years of age as well as health practitioners and other experts in Ukraine. Results were presented to stakeholders during a dialogue session to discuss the implications for policy recommendations. The Roma parents interviewed faced structural barriers to vaccine access, while other groups received vaccine information from others in their communities, such as family members or religious organisations. Mistrust of the health system and lack of access to reliable information preceded many doubts parents expressed surrounding vaccines. Stakeholders agreed that better, more targeted communication strategies are needed, as well as increased engagement with and training of medical practitioners. Qualitative methods allowed for a deeper, more nuanced understanding of the factors contributing to low vaccine uptake, of which vaccine hesitancy is only one part. The vulnerability-informed approach used may have broader applications for community engagement and responding to infectious diseases and crises.

SARS-CoV-2 infections in "less visible" hospital staff: The roles and safety of environmental services and allied health professionals.

BACKGROUND: During the early SARS-CoV-2 pandemic, all healthcare workers had specific and essential functions. However, environmental services (e.g., cleaning staff) and allied health professionals (e.g., physiotherapists) are often less recognised inpatient care. The aim of our study was to evaluate SARS-CoV-2-infection rates and describe risk factors relevant to workplace transmission and occupational safety amongst healthcare workers in COVID-19 hospitals before the introduction of SARS-CoV-2-specific vaccines. METHODS: This cross-sectional study (from May 2020 to March 2021, standardised WHO early-investigation protocol) is evaluating workplace or health-related data, COVID-19-patient proximity, personal protective equipment (PPE) use, and adherence to infection prevention and control (IPC) measures, anti-SARS-CoV-2-antibody status, and transmission pathways. RESULTS: Out of n = 221 HCW (n = 189 cleaning/service staff; n = 32 allied health professionals), n = 17 (7.7 %) were seropositive. While even SARS-CoV-2-naïve HCW reported SARS-CoV-2-related symptoms, airway symptoms, loss of smell or taste, and appetite were the most specific for a SARS-CoV-2-infection. Adherence to IPC (98.6 %) and recommended PPE use (98.2 %) were high and not associated with seropositivity. In 70.6 %, transmission occurred in private settings; in 23.5 %, at the workplace (by interaction with SARS-CoV-2-positive colleagues [17.6 %] or patient contact [5.9 %]), or remained unclear (one case). CONCLUSIONS: Infection rates were higher in all assessed 'less visible' healthcare-worker groups compared to the general population. Our data indicates that, while IPC measures and PPE may have contributed to the prevention of patient-to-healthcare-worker transmissions, infections were commonly acquired outside of work and transmitted between healthcare workers within the hospital. This finding emphasises the importance of ongoing education on transmission prevention and regular infection screenings at work.

Risk communication and community engagement with vulnerable groups: Perceptions of social-services CSOs during Covid-19.

Risk communication enables people to be prepared, respond and recover from public health risks which can only be realized with a considerable amount of community engagement. Enabling community involvement is necessary in order to reach and protect vulnerable people during epidemics. In situations of acute emergency, it is difficult to reach everyone, which makes it necessary to work with intermediaries such as social and care facilities and civil society organizations (CSOs) who work to support the most vulnerable in our societies. This paper analyses the perceptions of experts working in social facilities or CSOs of Covid-19 RCCE efforts in Austria. It starts from a broad understanding of vulnerability which combines medical, social and economic determinants. We conducted 21 semi-structured interviews with CSO and social facility managers. The UNICEF core community engagement standards (2020) were used as a framework for qualitative content analysis. The results show that CSO's and social facilities were essential for allowing community involvement of vulnerable people in Austria during the pandemic. For the CSO's and social facilities participation of their vulnerable clients was a real challenge especially because direct contact was difficult and public services were switched to digital only. Nonetheless, they all put a lot of effort into adapting and discussing Covid-19 regulations and measures with their clients and employees which in many cases led to acceptance of public health measures. The study gives recommendations on how community engagement could be enhanced especially from government actors and how CSO's could be addressed more as essential partners.

People Living with HIV and AIDS: Experiences towards Antiretroviral Therapy, Paradigm Changes, Coping, Stigma, and Discrimination-A Grounded Theory Study.

BACKGROUND: The experiences in coping with HIV/AIDS from people living with HIV (PLWH) in Austria, Munich, and Berlin regarding adherence, antiretroviral therapy (ART), stigmatization, and discrimination were the main focus of this study. Therapy adherence is the cornerstone for PLWH to reduce disease progression and increase life expectancy combined with a high quality of life. The experience of stigmatization and discrimination in different life situations and settings is still experienced today. AIMS: We aimed to examine the subjective perspective of PLWH concerning living with, coping with, and managing HIV/AIDS in daily life. METHODS: Grounded Theory Methodology (GTM) was used. Data collection was conducted with semi-structured face-to-face interviews with 25 participants. Data analysis was performed in three steps, open, axial, and selective coding. RESULTS: Five categories emerged, which included the following: (1) fast coping with diagnosis, (2) psychosocial burden due to HIV, (3) ART as a necessity, (4) building trust in HIV disclosure, (5) stigmatization and discrimination are still existing. CONCLUSION: In conclusion, it can be said that it is not the disease itself that causes the greatest stress, but the process of coping with the diagnosis. Therapy, as well as lifelong adherence, is hardly worth mentioning today. Much more significant is currently still the burden of discrimination and stigmatization.

Putting global health high on the agenda of medical schools.

In this opinion paper, we reflect on global health and global health education as well as challenges that the coming generation are likely to face. As the field is rapidly changing, it is vital to critically reflect categories of "global south" and "global north" as geographical boundaries, and rather think in terms of inequalities that are present in all countries. Global perspectives on health are useful to analyze structural challenges faced in all health care systems and help understand the diversity of cultures and patients' concepts of disease. We first discuss burning questions and important challenges in the field and how those challenges are tackled. Rather than going into detail on topical issues, we reflect on approaches and attitudes that we think are important in global health education and present opportunities and challenges for young scholars who are interested in working in this field.

The potential of medical comics to teach palliative care skills: a cross-sectional study of 668 medical students.

BACKGROUND: Palliative care (PC) skills are important when caring for patients with advanced illness in a broad range of settings. Students need to be trained in communication and empathy, both representing essential PC skills. Therefore, creative approaches could promote the understanding of relevant PC skills. METHODS: In an online lecture about graphic medicine, different medical comics (MC) were used to introduce the field of graphic medicine and to illustrate relevant skills in PC. After the lecture, an online survey was conducted. The survey consisted of each respondent`s sociodemographic profile and a questionnaire on multiple aspects related to the field of MC. Spearman correlation coefficients and Cohen's effect sizes were used for statistical analysis. RESULTS: The survey respondents comprised 668 students, 337 female, 326 male and 5 diverse. The results showed that the students had never (27.2%) or had very rarely (31.9%) been involved in with the field of MC. The largest number would rate their interest as somewhat or very interested (58.8%). When considering the use of MC to understand different perspectives, the students mainly rated them as useful (54.6%) or very useful (23.4%). Women had a more positive attitude towards MC than men (P<0.001). Students who placed more importance on PC skills were more likely to recommend the use of MC in general medical education (r=0.11, P=0.005). The majority of the students (58.8%) moderately or strongly agreed on the use of MC as a teaching method in PC. CONCLUSIONS: After a single lecture on graphic medicine, the students were positive about using MC for teaching PC skills. Since the lecture was short and the majority of the medical students stated that they had not been previously exposed to the field of MC, this study demonstrates that it is promising to further use and evaluate a set of visual and narrative illustrations as a teaching method in PC.

Vulnerability and One Health assessment approaches for infectious threats from a social science perspective: a systematic scoping review.

Vulnerability assessments identify vulnerable groups and can promote effective community engagement in responding to and mitigating destabilising events. This scoping review maps assessments for local-level vulnerabilities in the context of infectious threats. We searched various databases for articles written between 1978 and 2019. Eligible documents assessed local-level vulnerability, focusing on infectious threats and antimicrobial resistance. Since few studies provided this dual focus, we included tools from climate change and disaster risk reduction literature that engaged the community in the assessment. We considered studies using a One Health approach as essential for identifying vulnerability risk factors for zoonotic disease affecting humans. Of the 5390 records, we selected 36 articles for review. This scoping review fills a gap regarding vulnerability assessments by combining insights from various approaches: local-level understandings of vulnerability involving community perspectives; studies of social and ecological factors relevant to exposure; and integrated quantitative and qualitative methods that make generalisations based on direct observation. The findings inform the development of new tools to identify vulnerabilities and their relation to social and natural environments.

Occupational challenges of healthcare workers during the COVID-19 pandemic: a qualitative study.

OBJECTIVES: To address structural determinants and healthcare workers' (HCWs) physical, mental, emotional and professional challenges of working during the COVID-19 pandemic. DESIGN: Exploratory qualitative study with semistructured interviews. Collected data were analysed using thematic analysis. SETTING: This qualitative study was undertaken with HCWs who mainly worked in intensive care units in six non-profit hospitals in Vienna, Austria. Data were collected from June 2020 to January 2021. PARTICIPANTS: A total of 30 HCWs (13 medical doctors, 11 qualified nursing staff, 2 nurse assistants, 2 physiotherapists and 2 technical/cleaning staff) who were in direct and indirect contact with patients with COVID-19 were included. RESULTS: Three overall themes resulted as relevant: challenges due to lack of preparedness, structural conditions, and physical and mental health of HCWs. Lack of preparedness included delayed infection prevention and control (IPC) guidelines, shortages of personal protective equipment combined with staff shortages (especially of nursing staff) and overworked personnel. Physical and mental strains resulted from HCWs being overworked and working permanently on alert to face medical uncertainties and the critical conditions of patients. HCWs lacked recognition on multiple levels and dealt with stigma and avoidance behaviour of colleagues. CONCLUSION: To mitigate HCWs' occupational health risks and staff turnover, we propose context-specific recommendations. The number of available essential workers in care of patients with COVID-19, especially nursing staff, should be carefully planned and increased to avert chronic work overload. Timely training and education in IPC for all HCWs is important. Providing supportive supervision is as essential as appropriate recognition by higher level management and the public.

'I'm not an anti-vaxer!'-vaccine hesitancy among physicians: a qualitative study.

BACKGROUND: Over the last years, research interest in vaccine hesitancy has increased. Studies usually focus on perceptions of parents and have largely neglected the group of health care providers. However, doctors' notions on vaccination have a major impact on the decision-making process of their patients. We were interested to understand the phenomenon of vaccine hesitancy among physicians, with a particular focus on the measles vaccine. Furthermore, we aimed to understand the underlying perceptions of measles that may be associated with vaccine hesitant decisions. METHODS: In order to get an in-depth view, semi-structured interviews with physicians were conducted. Doctors were eligible for the study if they articulated vaccine hesitant views and/or demonstrated vaccine hesitancy in their medical practice. RESULTS: We interviewed 12 physicians, of whom 11 had a medical practice with no contract with the Austrian social insurance ('Wahlarzt') and additional training in complementary and alternative medicine. We found perceptions of immunology, health and illness that were discordant with evidence-based medicine and closely related to alternative and complementary medicine. All participants argued for a delayed administration of the measles vaccine. We found a consistent inclination towards 'individual vaccination', which was explained as empowering parents and to strengthen their decision-making competencies. Most participants expressed doubts about the reliability of vaccine studies and were concerned with possible long-term effects. CONCLUSIONS: Paying closer attention to doctors' concerns on vaccination might help to design target-oriented interventions to specifically strengthen vaccine confidence.

Beyond the "information deficit model" - understanding vaccine-hesitant attitudes of midwives in Austria: a qualitative study.

BACKGROUND: Healthcare workers are considered key stakeholders in efforts to address vaccine hesitancy. Midwives' influence in advising expectant parents on early-childhood vaccinations is unquestioned, yet they remain an understudied group. The literature on midwives' attitudes towards vaccinations is also inconclusive. We therefore conducted an explorative qualitative study on midwives' vaccine-hesitant attitudes towards MMR (measles-mumps-rubella) vaccinations in Austria. METHODS: We conducted 12 in-depth interviews on their knowledge, concerns, and beliefs with midwives who self-identified as hesitant or resistant towards early-childhood MMR vaccinations. We analyzed the data using a grounded theory approach to distill common themes and meanings. RESULTS: Healthcare workers' stewardship to address vaccine hesitancy is commonly framed in terms of the "information deficit model": disseminate the right information and remedy publics' information deficits. Our findings suggest that this approach is too simplistic: Midwives' professional self-understanding, their notions of "good care" and "good parenthood" inflect how they engage with vaccine information and how they address it to their clients. Midwives' model of care prioritized good counseling rather than sharing scientific information in a "right the wrong"-manner. They saw themselves as critical consumers of that information and as promoting "empowered patients" who were free, and affluent enough, to make their own choices about vaccinations. In so doing, they also often promoted traditional notions of motherhood. CONCLUSIONS: Research shows that, for parents, vaccine decision-making builds on trust and dialogue with healthcare professionals and is more than a technical issue. In order to foster these interactions, understanding healthcare professionals' means of engaging with information is key to understanding how they engage with their constituents. Healthcare workers are more than neutral resources; their daily praxis influenced by their professional standing in the healthcare system. Similarly, healthcare professionals' views on vaccinations cannot be remedied with more information either. Building better and more diverse curricula for different groups of healthcare workers must attend to their respective roles, ethics of care, and professional beliefs. Taken together, better models for addressing vaccine hesitancy can only be developed by espousing a multi-faceted view of decision-making processes and interactions of healthcare workers with constituents.

Community engagement and vulnerability in infectious diseases: A systematic review and qualitative analysis of the literature.

The global response to infectious diseases has seen a renewed interest in the use of community engagement to support research and relief efforts. From a perspective rooted in the social sciences, the concept of vulnerability offers an especially useful analytical frame for pursuing community engagement in a variety of contexts. However, few have closely examined the concept of vulnerability in community engagement efforts, leading to a need to better understand the various theories that underline the connections between the two. This literature review searched four databases (covering a total of 537 papers), resulting in 15 studies that analyze community engagement using a framing of vulnerability, broadly defined, in the context of an infectious disease, prioritizing historical and structural context and the many ways of constituting communities. The review identified historical and structural factors such as trust in the health system, history of political marginalization, various forms of racism and discrimination, and other aspects of vulnerability that are part and parcel of the main challenges faced by communities. The review found that studies using vulnerability within community engagement share some important characteristics (e.g., focus on local history and structural factors) and identified a few theoretical avenues from the social sciences which integrate a vulnerability-informed approach in community engagement. Finally, the review proposes an approach that brings together the concepts of vulnerability and community engagement, prioritizing participation, empowerment, and intersectoral collaboration.

Perceptions on the collection of body fluids for research on persistence of Ebola virus: A qualitative study.

BACKGROUND: Against the background of the international public health emergency related to the Ebola outbreak in the Democratic Republic of Congo, in addition to other recent large Ebola epidemics, the issue of transmission due to viral persistence from survivors' body fluids is becoming increasingly urgent. Clinical research in which body fluids play a role is critical and semen testing programs are part of the suggested response to the outbreak. Broad acceptance and understanding of testing programs and research, often in resource poor settings, is essential for the success and sustainability of clinical studies and an accurate epidemic response. Study participants' perceptions on the collection of body fluids are therefore relevant for the programmatic planning and implementation of clinical studies. STUDY AIM AND METHODS: In this qualitative study we aimed to explore the perceptions on bio-sampling in the Sierra Leone Ebola Virus Persistence Study (SLEVP study). We were interested to understand how norms on gender and sexuality related to perceptions and experiences of study participants and staff, specifically, in what way perceptions of the body, on intimacy and on body fluids related to the study process. We purposively sampled former study participants for in-depth interviews and focus-group discussions. We conducted 56 in-depth interviews and eight focus group discussions with 93 participants. In a participatory approach we included study participants in the analysis of data. RESULTS: Overall the SLEVP study was well perceived by study participants and study staff. Study participants conceived the testing of their body fluids positively and saw it as a useful means to know their status. However, some study participants were ambivalent and sometimes reluctant towards sampling of certain body fluids (especially semen, blood and vaginal fluid) due to religious or cultural reasons. Self-sampling was described by study participants as a highly unusual phenomenon. Several narratives were related to the loss of body fluids (especially semen) that would make men weak and powerless, or women dizzy and sick (especially blood). Some rumors indicated mistrust related to study aims that may have been expressions of broader societal challenges and historical circumstances. These reservations could eventually be overcome by guaranteeing confidentiality and privacy and by comprehensive professional counseling. CONCLUSION: In the course of the sampling exercise, study participants were often obliged to transgress cultural and intimate boundaries. It is therefore important to understand the potential importance some of these perceptions have on the recruitment of study participants and the acceptability of studies, on a symbolic as well as a structural level. In order to capture any reservations it is necessary to provide plenty of possibilities of information sharing and follow-up of continuous consent.

Yellow Fever Vaccine Safety Perception of Pregnant Women in Emergency Response Mass Vaccination in Uganda.

Yellow fever vaccine, a live attenuated vaccine, is primarily administered to pregnant women during outbreaks. A qualitative study was conducted in pregnant women on the perception of yellow fever mass vaccination. In total, interviews with 20 women-13 semi-structured interviews and one focus group discussion with seven participants-were analyzed. This study showed that conflicting information about vaccine safety led to concern about miscarriage. Furthermore, it was believed that vaccination during gestation would concurrently immunize the fetus by transplacental antibody transfer. Consultation of health workers at the vaccination site led to diverse recommendations. When vaccinating pregnant women, clear health communication is crucial. Vaccine recommendations should be obeyed, and health workers should be trained to address emerging vaccine concerns. Pregnant women should be informed that a booster dose is recommended to achieve lifelong immunity. After pregnancy, a booster should be offered to women in endemic areas.

Vulnerability assessment tools for infectious threats and antimicrobial resistance: a scoping review protocol.

INTRODUCTION: This protocol will guide and explain the working process of a systematic scoping review on vulnerability assessment tools in the field of infectious disease outbreaks and antimicrobial resistance (AMR) crises. The scoping review will appraise existing tools or methodologies to identify local level vulnerabilities in the context of infectious disease outbreaks and AMR. Due to this focus on infectious threats and AMR, the review also considers articles using a 'One Health' approach to assess the vulnerability of individuals, groups and practices in human-animal-environment interactions. Given the broad nature of vulnerability, we aim to allocate studies discerning the process of identifying vulnerable or at-risk groups during a crisis, instead of studies taking vulnerability only as a starting point. Because considerable research has been conducted on vulnerability, disasters and climate change, we will also assemble tools developed from these fields. To our knowledge, this is the first planned systematic scoping review of vulnerability assessment tools for disease outbreaks and AMR, taking into account practices at the human-animal-environment interface that can lead to increased risk of exposure of individuals to infections, pathogen spillovers or epidemics. METHODS AND ANALYSIS: To develop the protocol, we used the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols checklist (PRISMA-P 2015) in compliance with the PRISMA Extension for Scoping Reviews Explanation and Elaboration. With the assistance of an experienced research librarian, we developed the search strategy, which targeted the following databases: Medline, Global Health database, Web of Science and Embase. A second strategy was developed for Epistemonikos, African Journals Online and Global Index Medicus because these databases do not provide the infrastructure for an advanced search. We consider studies published between 1978 and 2019 and include articles, book chapters, websites and grey literature from selected non-governmental organisations and non-profit organisations working in the health field. We contact them directly regarding whether they are working with or have developed a vulnerability assessment tool. To address the dynamic nature of our investigation, we develop a flow diagram which we continually update to reflect the selection process. Two reviewers (MJ and LL) independently screen the literature and resolve conflicts through discussion rounds. Data extraction will be conducted by four researchers (MJ, LL, EJ and RK) through inductive and deductive coding. Extracted data will be systematically compared and divergences highlighted. ETHICS AND DISSEMINATION: Ethical approval is not required because this study does not involve collection of primary data. The purpose of this review is to disseminate a catalogue of vulnerability assessment tools and a brief summary of key results and recommendations for SoNAR-Global partners in Bangladesh, Ukraine and Uganda. The catalogue will be made publicly available. On the basis of our results, SoNAR-Global partners will pilot one of these tools.