Development and validation of the Vaccine Barriers Assessment Tool for identifying drivers of under-vaccination in children under five years in Australia.

Data on routine childhood vaccination coverage can only tell us who is under-vaccinated; it cannot explain why vaccine coverage is low. Collecting data on the reasons behind under-vaccination is necessary to implement cost-effective strategies that address key barriers and target interventions appropriately. However, no instruments that measure both vaccine acceptance and access factors among parents of children <5 y have been validated in high-income countries. This study aims to develop and validate the Vaccine Barriers Assessment Tool (VBAT) for Australia. We applied three phases of mixed methods data collection and analysis. In Phase 1, we developed a comprehensive list of 80 items reflecting all potential parental barriers to childhood vaccination, derived from published literature and behavioral theory. Through cognitive interviews (n = 28), we refined this list to 45 items. In Phase 2, we conducted a two-wave online survey to test the reliability and validity of these items in an Australian sample of parents (n = 532) with structural equation modeling, further refining the list to 35 items. In Phase 3, we conducted a final parent survey (n = 156), administering these items along with the Parent Attitudes toward Childhood Vaccination (PACV) scale for comparison. We reviewed participants' immunization register data to assess the predictive validity of the proposed models. The final 6-item short form and 15-item long form Vaccine Barriers Assessment Tool assess access, communal benefit, personal risk, equity, commitment, social norms, and trust in health-care workers. It is being applied for national surveillance in Australia and will be adapted for additional populations and vaccines.

The role of hesitancy and infrastructure in the equity and efficiency of COVID-19 vaccine administration.

After the first COVID-19 vaccines received emergency use authorization from the U.S. FDA in December 2020, U.S. states employed vaccine eligibility and administration plans (VEAPs) that determined when subgroups of residents would become eligible to receive the vaccine while the vaccine supply was still limited. During the implementation of these plans, public concern grew over whether the VEAPs and vaccine allocations from the federal government were resulting in an equitable and efficient vaccine distribution. In this study, we collected data on five states' VEAPs, federal vaccine allocations, vaccine administration, and vaccine hesitancy to assess the equity of vaccine access and vaccine administration efficiency that manifested during the campaign. Our results suggest that residents in states which opened eligibility to the vaccine sooner had more competition among residents to receive the vaccine than occurred in other states. Regardless of states' VEAPs, there was a consistent inefficiency in vaccine administration among all five states that could be attributed to both state and federal infrastructure deficits. A closer examination revealed a misalignment between federal vaccine allocations and the total eligible population in the states throughout the campaign, even when accounting for hesitancy. We conclude that in order to maximize the efficiency of future mass-vaccination campaigns, the federal and state governments should design adaptable allocation policies and eligibility plans that better match the true, real-time supply and demand for vaccines by accounting for vaccine hesitancy and manufacturing capacity. Further, we discuss the challenges of implementing such strategies.

How Technology, Health Information Seeking, and Socioeconomic Factors Are Associated With Coronavirus Disease 2019 Vaccination Readiness in Estonians Over 50 Years?

Despite the proven effectiveness of COVID-19 vaccines in preventing severe illness, many individuals, including older adults who are most susceptible to the virus, have opted against vaccination. Various factors could shape vaccination decisions, including seeking health information (HI). The internet is the primary source of HI today; however, older adults are often referred to as those missing out on digital benefits. The study explores the correlations between information and communication technology (ICT) use, online HI seeking, socioeconomic factors, and COVID-19 vaccination readiness among individuals aged 50 and above in Estonia. The survey data were gathered from 501 people aged 50 and older after the first lockdown in 2020. The outcomes revealed that vaccination readiness positively correlated with factors such as higher educational attainment, greater income, male gender, access to ICT, a readiness to employ digital technologies for health-related purposes, a greater demand for HI, and a higher frequency of seeking it online. There was some discrepancy in the preference of HI sources; for example, vaccination consenters preferred online versions of professional press publications and specific health portals. Based on the findings, it is advisable to encourage older adults to utilize the internet and new technology for health-related purposes. This practice expands the range of information sources available to them, ultimately enabling better decision-making regarding their health behaviors.

A psychometric assessment of a novel scale for evaluating vaccination attitudes amidst a major public health crisis.

Despite abundant scientific evidence supporting immunization benefits, vaccine hesitancy remains a significant global health concern, particularly during public health crises. Exploring public attitudes towards vaccination is crucial. This study aimed to develop and validate a tailored Public Vaccination Attitudes Scale specifically under the unique circumstances of a public health crisis. A psychometric evaluation was conducted using a cross-sectional study during the peak of a major public health crisis. The scale was developed and its psychometric properties validated using three approaches: (1) generating the item pool through literature research and focus group discussions; (2) assessing the items through expert consultation; and (3) evaluating construct validity, content validity, and internal consistency reliability through exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Data from a total of 3921 respondents were randomly divided into two subsets, one for EFA (n = 1935) and the other for CFA (n = 1986). A 22-item draft scale with five factors was created after literature research and focus group discussion. The content validity of this scale ranged between 0.88 and 1.00. EFA showed a 17-item scale with four factors (Cronbach's α > 0.7) accounting for 68.044% of the total variance. CFA showed that the values of the fit indices, including convergent validity and discriminant validity, were excellent or acceptable. The overall Cronbach's α was 0.874, and each factor ranged from 0.726 to 0.885. This study introduces a valuable tool for assessing vaccination attitudes during public health crises, aiding researchers, policymakers, and nurses in combating vaccine hesitancy. Emphasizing the importance of fostering vaccine acceptance, it enhances disease control during emergencies, contributing to the knowledge needed for more effective public health strategies and crisis responses.

Presidents and vaccines: head of state inoculation as a tool for vaccine promotion.

Introduction: Vaccine hesitancy, an important threat to global health, has increased since the onset of the COVID-19 pandemic. The public vaccination of high-profile figures, such as heads of state, has been touted as a potential tool for increasing vaccine acceptance among the general population. However, systematic information on such role modelling is lacking and existing studies focus on a small number of high-income countries. We take advantage of the COVID-19 pandemic to fill this gap. Methods: Through a systematic search of internet sources, we first document that most global leaders supported the vaccination campaign and actively communicated their vaccination status to the public. We then turn to a case study to provide experimental evidence on vaccine role modelling for a country in Africa - the region that is most lagging behind in achieving universal immunization coverage. We rely on a randomized survey experiment with 600 citizens in the Democratic Republic of Congo and take advantage of the fact that the Congolese President publicly received a COVID-19 vaccine during the survey period. Results and discussion: Our findings demonstrate that the impact of political leader's role modelling is moderated by trust and depends on media outreach and access. When trust in leaders is lacking, or news on their actions is inaccessible, alternative ambassadors and effective communication methods become crucial in motivating and informing the public. This may be especially relevant in fragile states and remote regions.

Assessment of the impact of the vaccine pass policy on COVID-19 vaccine hesitancy and uptake among Chinese adults in Hong Kong.

BACKGROUND: Recognising the importance of attaining high vaccine coverage to mitigate the COVID-19 impact, a Vaccine Pass scheme was implemented during and after the first large Omicron wave with high mortality in older ages in Hong Kong in early 2022 requiring three doses by June 2022. We did not identify any studies evaluating the policy impact of vaccination mandates with vaccine uptake over whole policy period of time in a Chinese population. We aim to evaluate the impact of the Vaccine Pass policy on COVID-19 vaccine uptake in adults in a Chinese population in Hong Kong. METHODS: We analysed patterns in vaccine uptake and hesitancy using local data from population vaccine registry and 32 cross-sectional telephone surveys conducted from October 2021 to December 2022. The association of Vaccine Pass phases with vaccine uptake was examined using logistic regression analyses, taking into account covariates including self-risk perception, perceived self-efficacy in preventing COVID-19 and trust in government in pandemic control as well as physical distancing measures and demographics. RESULTS: The uptake of primary series and third doses was positively significantly associated with the successive stages of Vaccine Pass implementation (adjusted odds ratios ranged from 2.41 to 7.81). Other statistically significant drivers of uptake included age group, chronic condition, higher perceived personal susceptibility to COVID-19, higher trust in government, and higher educational attainment. CONCLUSION: Vaccine uptake in older adults was observed to have increased by a greater extent after the policy annoucement and implementation, under the contextual changes during and after a large Omicron wave with high mortality in Hong Kong in early 2022. Since the policy withdrawal the uptake of further booster doses has been very low in all ages. We suggest that improving voluntary booster uptake in older adults should be prioritized.

Vaccine hesitancy in South Tyrol: a narrative review of insights and strategies for public health improvement.

Introduction: This review examines vaccine hesitancy in South Tyrol, Italy, a region characterized by cultural and linguistic diversity. The critical need for vaccination to control infectious diseases contrasts with the region's low vaccination rates, which pose a significant public health challenge. Methods: Based on literature, reports, and studies, we used PubMed, Embase, and Google Scholar to explore vaccine hesitancy in South Tyrol. It emphasizes the analysis of historical, cultural, and socioeconomic factors, and focuses on quantitative surveys and qualitative interviews to understand the roots of vaccine hesitancy. Results: In two studies with four reports, mistrust in health policies and institutions, misinformation, and cultural and linguistic barriers were identified as key factors contributing to vaccine hesitancy in South Tyrol. These factors are accentuated by the region's unique sociopolitical landscape, which influences public health policies and vaccination initiatives. Conclusions: These findings highlight the need for public health strategies specifically tailored to South Tyrol. Recommended actions include developing culturally sensitive and multilingual communication campaigns, increasing community involvement, and rebuilding trust in healthcare systems. These approaches are essential for addressing the specific challenges in South Tyrol, thereby improving vaccine uptake and overall public health outcomes.

A community-engaged approach to translate a Vaccine Hesitancy Scale into Haitian Creole.

OBJECTIVE: Accurately translated health materials are needed to achieve equity in vaccine uptake among U.S. individuals with non-English language preferences. Verbatim translations may not capture the cultural and linguistic vernacular required to understand vaccine hesitancy. We leveraged a community-engaged approach to translate the Vaccine Hesitancy Scale (VHS) into Haitian Creole. METHODS: Following the "WHO Guidelines on Translation and Adaptation of Instruments" and a community-engaged framework, a validated 10-question Vaccine Hesitancy Scale (VHS) underwent forward translation, expert panel review, back translation, and focus group pilot testing. RESULTS: Haitian Creole-speaking translators included two community leaders, one community partner, one study team member, and 13 Haitian, greater Boston-based community members who participated in a focus group to pretest the survey. After four iterations, a linguistic and cultural translation of the VHS was created. CONCLUSION: A community-engaged framework strengthened community partnerships and resulted in a culturally relevant Haitian Creole vaccine hesitancy scale.

Community based participatory research as a promising practice for addressing vaccine hesitancy, rebuilding trust and addressing health disparities among racial and ethnic minority communities.

The COVID-19 pandemic disproportionately affected racial and ethnic minority communities across the United States (U.S.). Despite the disproportionate burden of COVID-19 faced by communities of color, Black and Hispanic communities are less likely to be fully vaccinated than White non-Hispanic Persons. Health inequity and vaccine hesitancy are complex phenomena that require multilevel responses tailored to the unique needs of each community, a process that inherently necessitates a high level of community engagement in order to develop the most effective health interventions. Building on the principles of community based participatory research (CBPR) and with the support of the National Institutes of Health (NIH), Project 2VIDA! was born. A multidisciplinary collaborative of academic researchers, community members, and clinicians whose aim is to foster sustainable partnerships to reduce the burden of COVID-19 in Hispanic and Black communities across Southern California. Our model was designed to meet our community members where they were - whether on their lunch break or picking their children from school. This CBPR model has been well received by community members. Future health interventions focused on reducing health disparities should prioritize the role of the community, leverage the voices of key community partners, and be grounded in equitable power sharing.

Last-mile delivery increases vaccine uptake in Sierra Leone.

Less than 30% of people in Africa received a dose of the COVID-19 vaccine even 18 months after vaccine development1. Here, motivated by the observation that residents of remote, rural areas of Sierra Leone faced severe access difficulties2, we conducted an intervention with last-mile delivery of doses and health professionals to the most inaccessible areas, along with community mobilization. A cluster randomized controlled trial in 150 communities showed that this intervention with mobile vaccination teams increased the immunization rate by about 26 percentage points within 48-72 h. Moreover, auxiliary populations visited our community vaccination points, which more than doubled the number of inoculations administered. The additional people vaccinated per intervention site translated to an implementation cost of US $33 per person vaccinated. Transportation to reach remote villages accounted for a large share of total intervention costs. Therefore, bundling multiple maternal and child health interventions in the same visit would further reduce costs per person treated. Current research on vaccine delivery maintains a large focus on individual behavioural issues such as hesitancy. Our study demonstrates that prioritizing mobile services to overcome access difficulties faced by remote populations in developing countries can generate increased returns in terms of uptake of health services3.

Vaccine hesitancy and equity: lessons learned from the past and how they affect the COVID-19 countermeasure in Indonesia.

INTRODUCTION: Indonesia has made progress in increasing vaccine coverage, but equitable access remains challenging, especially in remote areas. Despite including vaccines in the National Immunization Program (NIP), coverage has not met WHO and UNICEF targets, with childhood immunization decreasing during the COVID-19 pandemic. COVID-19 vaccination has also experienced hesitancy, slowing efforts to end the pandemic. SCOPE: This article addresses the issue of vaccine hesitancy and its impact on vaccination initiatives amidst the COVID-19 pandemic. This article utilizes the vaccine hesitancy framework to analyze previous outbreaks of vaccine-preventable diseases and their underlying causes, ultimately providing recommendations for addressing the current situation. The analysis considers the differences between the pre-pandemic circumstances and the present and considers the implementation of basic and advanced strategies. KEY FINDINGS AND CONCLUSION: Vaccine hesitancy is a significant challenge in the COVID-19 pandemic, and public health campaigns and community engagement efforts are needed to promote vaccine acceptance and uptake. Efforts to address vaccine hesitancy promote trust in healthcare systems and increase the likelihood of individuals seeking preventive health services. Vaccine hesitancy requires a comprehensive, culturally sensitive approach that considers local contexts and realities. Strategies should be tailored to specific cultural and societal contexts and monitored and evaluated.

Ethnic Disparities in COVID-19 Vaccine Mistrust and Receipt in British Columbia, Canada: Population Survey.

BACKGROUND: Racialized populations in the United States, Canada, and the United Kingdom have been disproportionately affected by COVID-19. Higher vaccine hesitancy has been reported among racial and ethnic minorities in some of these countries. In the United Kingdom, for example, higher vaccine hesitancy has been observed among the South Asian population and Black compared with the White population, and this has been attributed to lack of trust in government due to historical and ongoing racism and discrimination. OBJECTIVE: This study aimed to assess vaccine receipt by ethnicity and its relationship with mistrust among ethnic groups in British Columbia (BC), Canada. METHODS: We included adults ≥18 years of age who participated in the BC COVID-19 Population Mixing Patterns Survey (BC-Mix) from March 8, 2021, to August 8, 2022. The survey included questions about vaccine receipt and beliefs based on a behavioral framework. Multivariable logistic regression was used to assess the association between mistrust in vaccines and vaccine receipt among ethnic groups. RESULTS: The analysis included 25,640 adults. Overall, 76.7% (22,010/28,696) of respondents reported having received at least 1 dose of COVID-19 vaccines (Chinese=86.1%, South Asian=79.6%, White=75.5%, and other ethnicity=73.2%). Overall, 13.7% (3513/25,640) of respondents reported mistrust of COVID-19 vaccines (Chinese=7.1%, South Asian=8.2%, White=15.4%, and other ethnicity=15.2%). In the multivariable model (adjusting for age, sex, ethnicity, educational attainment, and household size), mistrust was associated with a 93% reduced odds of vaccine receipt (adjusted odds ratio 0.07, 95% CI 0.06-0.08). In the models stratified by ethnicity, mistrust was associated with 81%, 92%, 94%, and 95% reduced odds of vaccine receipt among South Asian, Chinese, White, and other ethnicities, respectively. Indecision, whether to trust the vaccine or not, was significantly associated with a 70% and 78% reduced odds of vaccine receipt among those who identified as White and of other ethnic groups, respectively. CONCLUSIONS: Vaccine receipt among those who identified as South Asian and Chinese in BC was higher than that among the White population. Vaccine mistrust was associated with a lower odds of vaccine receipt in all ethnicities, but it had a lower effect on vaccine receipt among the South Asian and Chinese populations. Future research needs to focus on sources of mistrust to better understand its potential influence on vaccine receipt among visible minorities in Canada.

COVID-19 vaccine hesitancy among American Indian and Alaska native college students: the roles of discrimination, historical trauma, and healthcare system distrust.

For American Indians and Alaska Native (AIAN) and other communities of color, experiences with discrimination and historical trauma may contribute to healthcare system distrust and negatively affect health care decisions, including vaccination. A saturated path analysis was conducted to examine the direct and indirect associations of thoughts regarding historical losses (of culture, language, and traditional ways) and AIAN racial discrimination with historical loss associated distress, healthcare system distrust, and COVID-19 vaccine hesitancy among AIAN college students (N = 391). Historical loss thoughts and experiences with racial discrimination were strongly associated with each other, and both were uniquely associated with greater historical loss associated distress. In turn, historical loss associated distress was associated with greater healthcare system distrust, which in turn was associated with greater likelihood of being COVID-19 vaccine hesitant. While further research is needed, the findings suggest that to address health disparities for AIAN people it is necessary to consider how to best overcome healthcare system distrust and factors that contribute to it, including historical trauma and contemporary experiences with discrimination.

Population Attributable Fraction of Nonvaccination of COVID-19 Due to Vaccine Hesitancy, United States, 2021.

Understanding the extent of coronavirus disease 2019 (COVID-19) nonvaccination attributable to vaccine hesitancy versus other barriers can help prioritize approaches for increasing vaccination uptake. Using data from the Centers for Disease Control and Prevention's Research and Development Survey, a nationally representative survey fielded from May 1 to June 30, 2021 (n = 5,458), we examined the adjusted population attribution fraction (PAF) of COVID-19 vaccine hesitancy attributed to nonvaccination according to sociodemographic characteristics and health-related variables. Overall, the adjusted PAF of nonvaccination attributed to vaccine hesitancy was 76.1%. The PAF was highest among adults who were ≥50 years of age (87.9%), were non-Hispanic White (83.7%), had a bachelor's degree or higher (82.7%), had an annual household income of at least $75,000 (85.5%), were insured (82.4%), and had a usual place for health care (80.7%). The PAF was lower for those who were current smokers (65.3%) compared with never smokers (77.9%), those who had anxiety or depression (65.2%) compared with those who did not (80.1%), and those who had a disability (64.5%) compared with those who did not (79.2%). Disparities in PAF suggest areas for prioritization of efforts for intervention and development of messaging campaigns that address all barriers to uptake, including hesitancy and access, to advance health equity and protect individuals from COVID-19.

Promoting data harmonization to evaluate vaccine hesitancy in LMICs: approach and applications.

BACKGROUND: Factors influencing the health of populations are subjects of interdisciplinary study. However, datasets relevant to public health often lack interdisciplinary breath. It is difficult to combine data on health outcomes with datasets on potentially important contextual factors, like political violence or development, due to incompatible levels of geographic support; differing data formats and structures; differences in sampling procedures and wording; and the stability of temporal trends. We present a computational package to combine spatially misaligned datasets, and provide an illustrative analysis of multi-dimensional factors in health outcomes. METHODS: We rely on a new software toolkit, Sub-National Geospatial Data Archive (SUNGEO), to combine data across disciplinary domains and demonstrate a use case on vaccine hesitancy in Low and Middle-Income Countries (LMICs). We use data from the World Bank's High Frequency Phone Surveys (HFPS) from Kenya, Indonesia, and Malawi. We curate and combine these surveys with data on political violence, elections, economic development, and other contextual factors, using SUNGEO. We then develop a stochastic model to analyze the integrated data and evaluate 1) the stability of vaccination preferences in all three countries over time, and 2) the association between local contextual factors and vaccination preferences. RESULTS: In all three countries, vaccine-acceptance is more persistent than vaccine-hesitancy from round to round: the long-run probability of staying vaccine-acceptant (hesitant) was 0.96 (0.65) in Indonesia, 0.89 (0.21) in Kenya, and 0.76 (0.40) in Malawi. However, vaccine acceptance was significantly less durable in areas exposed to political violence, with percentage point differences (ppd) in vaccine acceptance of -10 (Indonesia), -5 (Kenya), and -64 (Malawi). In Indonesia and Kenya, although not Malawi, vaccine acceptance was also significantly less durable in locations without competitive elections (-19 and -6 ppd, respectively) and in locations with more limited transportation infrastructure (-11 and -8 ppd). CONCLUSION: With SUNGEO, researchers can combine spatially misaligned and incompatible datasets. As an illustrative example, we find that vaccination hesitancy is correlated with political violence, electoral uncompetitiveness and limited access to public goods, consistent with past results that vaccination hesitancy is associated with government distrust.

Informing efforts beyond tailored promotional campaigns by understanding contextual factors shaping vaccine hesitancy among equity-deserving populations in Canada: an exploratory qualitative study.

BACKGROUND: Vaccine hesitancy exists on a continuum ranging between complete adherence and complete refusal due to doubts or concerns within a heterogeneous group of individuals. Despite widespread acknowledgement of the contextual factors influencing attitudes and beliefs shaping COVID-19 vaccine hesitancy, qualitative research with equity-deserving groups, accounting for unique lived experiences, remains a gap in the literature. We aim to identify and begin to understand and document the unique contextual factors shaping hesitancy by equity-deserving groups as it relates to relationships with government and health authorities. METHODS: Participants were recruited and interviewed between Aug-Dec 2021. Semi-structured interviews using a convergent interviewing technique were conducted with individuals from the general population, as well as individuals who identify as First Nations, Métis, or Inuit, members of the LGBT2SQ + community, low-income Canadians, Black Canadians, and newcomers. Interviews were audio recorded and transcribed by a team of researchers. Memos were written following interviews and used to complement the thematic analysis of the interview data. Themes are presented in the results section. RESULTS: The rationale for hesitancy among equity-deserving groups is consistent with literature documenting hesitancy in the general population. Contextual factors surrounding equity-deserving groups' attitudes and beliefs, however, are unique and relate to a history of oppression, discrimination, and genocide. We identified factors unique to subgroups; for example, religious or fatalistic beliefs among participant who identify as FNMI, fear associated with lack of testing and speed of vaccines' production among participants who identify as FNMI, Black, and LGBT2SQ + , distrust of the healthcare system for LGBT2SQ + and Black Canadians, and distrust of the government and opposition to vaccine mandates for participating who identify as LGBT2SQ + , low-income, FNMI, or Black Canadian. Newcomers stood out as very trusting of the government and accepting of COVID-19 vaccination. CONCLUSIONS: While our data on vaccine hesitancy largely mirror concerns reported in the vast body of literature citing rationale for COVID-19 hesitancy in high-income countries, the contextual factors identified in our work point to the need for wider systemic change. Our results may be used to support efforts, beyond tailored promotion campaigns, to support the confident acceptance of vaccines for COVID-19 and the acceptance of novel vaccines as future infectious diseases emerge.

Pandemic stressors and vaccine hesitancy among young, pregnant Black people: A qualitative study of health disparities during a global pandemic.

BACKGROUND: The novel coronavirus 2019 (COVID-19) pandemic exacerbated existing health inequities in the United States, but no studies have focused on the lived experiences of younger Black birthing people. The goal of this qualitative study was to center the experiences of younger pregnant and birthing Black and Biracial people during the pandemic. METHODS: We recruited 25 Black and Biracial pregnant and birthing people ages 16-23 for individual semi-structured interviews. Participants were asked about experiences with the healthcare system during the pandemic, and interviews were transcribed verbatim and coded for qualitative analysis using nVivo. We adhered to the Consolidated Criteria for Reporting Qualitative Research guidelines. RESULTS: Participants identified pandemic-related stressors such as fears about infection, lack of support, and pressure to get vaccinated. Reasons for vaccine hesitancy included mistrust in the government and racism experienced during reproductive healthcare. Provider appeals highlighting patient autonomy and science were more effective in encouraging vaccine uptake than emotional appeals that made participants feel guilty about potentially infecting loved ones. CONCLUSIONS: Restrictions on children and support people created barriers to timely prenatal care and reduced tangible support for young Black and Biracial birthing people during the pandemic. Their vaccine hesitancy was related to mistrust, concerns that the vaccines had not been tested enough prior to roll-out, and possible side effects of the vaccine including infection with the virus and pregnancy loss. Obstetric providers need to understand and recognize the ongoing impact of obstetric and scientific racism on health communication with younger Black and Biracial patients.