Exploring pre-pandemic patterns of vaccine decision-making with the 5C model: results from representative surveys in 2016 and 2018.

BACKGROUND: The 5C psychological antecedents of vaccination (Confidence, Complacency, Constraints, Calculation, and Collective Responsibility) facilitate understanding vaccination decisions in specific target groups as well as the general public's informational needs. This study aims to explain pre-pandemic vaccination behaviour (a) in general, (b) for specific vaccines such as influenza, and (c) for certain target groups (e.g. people over the age of 59 years, parents, healthcare workers), using the 5C model and sociodemographic variables. The intention to get an influenza vaccination was also analysed for target groups. METHODS: The 5C, self-reported vaccination behaviour and the intention to vaccinate were collected in two representative telephone surveys in Germany - one in 2016 (n1 = 5,012) and another in 2018 (n2 = 5,054). Parents, people over the age of 59 years, chronically ill people, people with a migratory background, pregnant women and healthcare workers were target groups. RESULTS: Overall, the 5C model had higher explanatory power than sociodemographic variables. The pattern of vaccine hesitancy slightly differed between vaccinations and target groups. Confidence in safety and effectiveness was always a significant predictor. Complacency (the underestimation of disease risks) and Constraints were significant predictors as well. Calculation (of risks and benefits) was important for influenza vaccination intentions. CONCLUSIONS: This work builds an important benchmark for understanding potential changes in vaccine acceptance due to the pandemic. The benchmark can be used in research on potential effects of the pandemic on vaccination behaviours. Intervention designers can also use the results to understand specific audiences and their vaccination decisions.

Empirical evidence to understand the human factor for effective rapid testing against SARS-CoV-2.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rapid antigen point-of-care and home tests are available to laypeople. In four cross-sectional mixed-methods data collections conducted between December 2020 and March 2021 (n = 4,026), we showed that a majority of subjects were willing to test despite mistrust and ignorance regarding rapid tests' validity. Experimental evidence shows that low costs and access to events could increase testing intentions. Mandatory reporting and isolation after positive results were not identified as major barriers. Instead, assuming that testing and isolation can slow down the pandemic and the possibility to protect others were related to greater willingness to get tested. While we did not find evidence for risk compensation for past tests, experimental evidence suggests that there is a tendency to show less mask wearing and physical distancing in a group of tested individuals. A short communication intervention reduced complacent behavior. The derived recommendations could make rapid testing a successful pillar of pandemic management.

Social and behavioral consequences of mask policies during the COVID-19 pandemic.

Mandatory and voluntary mask policies may have yet unknown social and behavioral consequences related to the effectiveness of the measure, stigmatization, and perceived fairness. Serial cross-sectional data (April 14 to May 26, 2020) from nearly 7,000 German participants demonstrate that implementing a mandatory policy increased actual compliance despite moderate acceptance; mask wearing correlated positively with other protective behaviors. A preregistered experiment (n = 925) further indicates that a voluntary policy would likely lead to insufficient compliance, would be perceived as less fair, and could intensify stigmatization. A mandatory policy appears to be an effective, fair, and socially responsible solution to curb transmissions of airborne viruses.

[Attitudes Toward Influenza Vaccination in Fall/Winter 2021: Results of the COSMO Study]. / Einstellung zur Grippeimpfung im Herbst/Winter 2021: Ergebnisse der COSMO-Studie.

AIM OF THE STUDY: There is a lack of knowledge about attitudes to influenza vaccination in Germany in 2021/2022. Based on the COSMO survey ("COVID-19 Snapshot Monitoring"), the aim of this study was to shed some light on this topic. METHODS: Wave 49 (August 10 and 11, 2021) of the COSMO survey (n=967; Germany-wide non-probabilistic quota sample; 18 to 74 years). RESULTS: This year, about one-third of respondents (and health care workers) plan to get a flu shot, and among the at-risk group of people aged 60 and older (up to 74 years in our sample), more than half. Correlates (such as gender: women with a lower likelihood of a planned flu shot) were identified. CONCLUSION: Physicians should inform women in particular about the advantages of influenza vaccination, especially during the pandemic, and communicate data on the proven protective effect of influenza vaccination as convincingly as possible (e. g., using existing brochures).

Allocation of COVID-19 vaccination: when public prioritisation preferences differ from official regulations.

As vaccines against COVID-19 are scarce, many countries have developed vaccination prioritisation strategies focusing on ethical and epidemiological considerations. However, public acceptance of such strategies should be monitored to ensure successful implementation. In an experiment with N=1379 German participants, we investigated whether the public's vaccination allocation preferences matched the prioritisation strategy approved by the German government. Results revealed different allocations. While the government had top-prioritised vulnerable people (being of high age or accommodated in nursing homes for the elderly), participants preferred exclusive allocation of the first available vaccines to medical staff and personnel caring for the elderly. Interestingly, allocation preferences did not change when participants were told how many individuals were included in each group. As differences between allocation policies and public preferences can affect trust in the government and threaten the social contract between generations, we discuss possible strategies to align vaccination prioritisations.

Money is not everything: experimental evidence that payments do not increase willingness to be vaccinated against COVID-19.

Rapid, large-scale uptake of new vaccines against COVID-19 will be crucial to decrease infections and end the pandemic. In a recent article in this journal, Julian Savulescu argued in favour of monetary incentives to convince more people to be vaccinated once the vaccine becomes available. To evaluate the potential of his suggestion, we conducted an experiment investigating the impact of payments and the communication of individual and prosocial benefits of high vaccination rates on vaccination intentions. Our results revealed that none of these interventions or their combinations increased willingness to be vaccinated shortly after a vaccine becomes available. Consequently, decision makers should be cautious about introducing monetary incentives and instead focus on interventions that increase confidence in vaccine safety first, as this has shown to be an especially important factor regarding the demand for the new COVID-19 vaccines.

The four weeks before lockdown during the COVID-19 pandemic in Germany: a weekly serial cross-sectional survey on risk perceptions, knowledge, public trust and behaviour, 3 to 25 March 2020.

BackgroundDuring the COVID-19 pandemic, public perceptions and behaviours have had to adapt rapidly to new risk scenarios and radical behavioural restrictions.AimTo identify major drivers of acceptance of protective behaviours during the 4-week transition from virtually no COVID-19 cases to the nationwide lockdown in Germany (3-25 March 2020).MethodsA serial cross-sectional online survey was administered weekly to ca 1,000 unique individuals for four data collection rounds in March 2020 using non-probability quota samples, representative of the German adult population between 18 and 74 years in terms of age × sex and federal state (n = 3,910). Acceptance of restrictions was regressed on sociodemographic variables, time and psychological variables, e.g. trust, risk perceptions, self-efficacy. Extraction of homogenous clusters was based on knowledge and behaviour.ResultsAcceptance of restrictive policies increased with participants' age and employment in the healthcare sector; cognitive and particularly affective risk perceptions were further significant predictors. Acceptance increased over time, as trust in institutions became more relevant and trust in media became less relevant. The cluster analysis further indicated that having a higher education increased the gap between knowledge and behaviour. Trust in institutions was related to conversion of knowledge into action.ConclusionIdentifying relevant principles that increase acceptance will remain crucial to the development of strategies that help adjust behaviour to control the pandemic, possibly for years to come. Based on our findings, we provide operational recommendations for health authorities regarding data collection, health communication and outreach.

[Public trust in institutions in the first half of the Corona pandemic: findings from the COVID-19 Snapshot Monitoring (COSMO) project]. / Vertrauen der Bevölkerung in staatliche Institutionen im ersten Halbjahr der Coronapandemie: Erkenntnisse aus dem Projekt COVID-19 Snapshot Monitoring (COSMO).

BACKGROUND: In the coronavirus pandemic, two institutions play a central role in the evidence-based classification of events for politics and the population. The Robert Koch Institute (RKI) coordinates the fight against the pandemic, prepares well-founded recommendations for medical professionals, the media and the population, and advises politicians. The Federal Centre for Health Education (BZgA) informs the population and institutions. GOALS: The COVID-19 Snapshot Monitoring (COSMO) project monitors whether and how trust in institutions changes over the pandemic. Which population groups show trust and how this is related to attitudes, risk perception and behaviour are analysed. METHODS: Cross-sectional studies with approximately N = 1000 respondents per survey were conducted since March 2020 to investigate risk perception, behaviour, acceptance of measures and trust in institutions. RESULTS: Trust in the RKI and BZgA was generally high but declined over the course of the pandemic. Higher trust for both institutions was associated with higher age of respondents, higher education, higher risk perception and higher acceptance of measures. Behaviours such as physical distancing and handwashing were shown more frequently. Men and the chronically ill showed lower trust. DISCUSSION: The results show that trust should be further promoted. This could be achieved, among other things, by taking into account the population's perspective (e.g. through COSMO) in the development and justification of strategies and measures. Communication strategies and recommendations for action should aim to support and relieve people with high-risk perceptions.

[Psychological antecedents of vaccination: definitions, measurement, and interventions]. / Impfverhalten psychologisch erklären, messen und verändern.

Vaccinations are among the safest and most effective ways to prevent morbidity and mortality from severe infectious diseases - both on an individual and societal level. Despite the availability of safe and effective vaccines some people decide against vaccination, which leads to recurrent outbreaks of vaccine-preventable diseases. In order to achieve the common goals of eliminating certain infectious diseases and to protect individual health, it is necessary to understand the antecedents of (non-)vaccination.The 5C model describes five relevant psychological antecedents of vaccination: confidence, complacency (risk perceptions), constraints (barriers), calculation (extent of information search), and collective responsibility (willingness to protect the community). This contribution provides an overview of how these antecedents can be measured on an individual level and how interventions should be designed and evaluated to address the respective antecedents.Data from Germany show that structural changes to reduce practical barriers are important to improve vaccine uptake. Thus, it is also important to address aspects beyond confidence.

Determinants of sepsis knowledge: a representative survey of the elderly population in Germany.

BACKGROUND: Sepsis is a life-threatening medical emergency requiring early diagnosis and urgent treatment. Knowledge is crucial, especially in major risk groups such as the elderly. We therefore assessed sophisticated knowledge about sepsis in the German elderly population. METHODS: A telephone survey was carried out with a representative sample of 701 Germans from 16 federal states and a separate cohort of 700 participants from Thuringia, all aged ≥ 60 years. Sepsis knowledge was assessed via a 10-item questionnaire. Sociodemographic data and health information sources were assessed to identify determinants of sepsis knowledge. RESULTS: Of the participants, 88.6% had heard the term "sepsis" before; however, 50% of these failed to define sepsis correctly. Even if the knowledge of symptoms was moderately good, most participants could not correctly identify causes of sepsis and underestimated its incidence. Only a minority was aware that immunization may prevent sepsis. Regressions revealed that being younger, better educated and living in rural areas predicted higher levels of sepsis knowledge. Pharmacists were a relevant source of sepsis information. CONCLUSIONS: Despite overall awareness of sepsis, the understanding of its risk factors, symptoms and prevention is low in the elderly, with important implications for emergency and intensive care. We suggest further educational measures to improve early sepsis recognition and prevention through vaccination.

Increasing influenza and pneumococcal vaccine uptake in the elderly: study protocol for the multi-methods prospective intervention study Vaccination60.

BACKGROUND: Influenza and pneumococcal vaccination can prevent disease and potentially life-threatening complications like sepsis. Elderly people have an increased risk of severe disease and therefore constitute a major target group for vaccination. To increase vaccination coverage, targeted interventions are needed that take theory-based specific determinants of vaccination behaviour into account. Moreover, message and campaign design should consider specific age-related characteristics (e.g., information processing, media use). The aim of this study is (i) to identify the specific informational and interventional needs of this risk group, (ii) to design and implement a targeted intervention aiming to decrease vaccine hesitancy, increase vaccine uptake and decrease the health and economic burden due to the respective diseases, and (iii) to measure the effect of this evidence-informed intervention on various levels. METHODS: Prospective, multi-methods intervention study targeting individuals aged ≥60 years in a model region in Germany (federal state of Thuringia, 500,000 inhabitants ≥60 years old). The development of the intervention follows theory-based and evidence-informed principles: Data from a cross-sectional representative study provide insights into specific determinants of the target group's vaccination behaviour. Additionally, media use is analysed to identify adequate communication channels for specific subgroups. In pilot studies, the intervention materials are adapted to the specific cognitive requirements of the target group. For development and implementation of the intervention, an interdisciplinary and trans-sectoral approach is used, including psychology, communication science, design, medical science, epidemiology and various public health players. The intervention will be implemented in autumn and winter 2017/18 and 2018/19 and adjusted in between. Evaluation of the intervention includes: awareness, use and recall of intervention materials, effects on changes in determinants of vaccination behaviour, self-reported vaccine uptake, and vaccination coverage in the intervention area (primary outcomes), as well as disease incidences (secondary outcomes) and the economic burden of influenza, pneumonia, invasive pneumococcal disease and sepsis for the healthcare system (tertiary outcomes). DISCUSSION: The data will add to the body of evidence on the effectiveness of evidence-informed vaccination campaign development as well as on the clinical and economic effects of pneumococcal and influenza vaccination. The effect of the intervention will teach valuable lessons about the principles of campaign development and evaluation, and can motivate a subsequent nationwide intervention. TRIAL REGISTRATION: DRKS00012653 . Registered 24.11.2017. Retrospectively registered.

Vicarious experiences of long COVID: A protection motivation theory analysis for vaccination intentions.

Context: Long COVID can appear as a severe late consequence (sequela) of a COVID-19 infection, leading to the inability to work or participate in social life for an unknown amount of time. To see friends or family struggling with long COVID might influence people's risk perceptions, vaccine efficacy expectations, and self-efficacy perceptions to prevent COVID-19 and its consequences. Methods: In an online survey in August 2022, n = 989 German-speaking participants indicated whether they knew someone who suffered from long COVID illness. Four dimensions of protection motivation theory (PMT) were assessed afterwards, as well as vaccination intentions. Results: Multiple mediation analysis with participants who knew vs. didn't know someone with long COVID (n = 767) showed that knowing someone with long COVID was associated with higher perceived affective and cognitive risk of long COVID-19 as well as higher perceived vaccine efficacy. Self-efficacy, i.e., the ease to protect oneself against long COVID, was lower in participants who knew long-COVID patients. Indirect positive effects for response efficacy and affective risk suggest that vicarious experience with long COVID is associated with increased intentions to get a COVID-19 vaccine. Conclusion: The protection from long COVID through vaccination are relevant aspects for individual decisions and health communication.

Breaking the endometriosis silence: a social norm approach to reducing menstrual stigma and policy resistance among young adults.

OBJECTIVE: Endometriosis is a menstrual disorder that affects one in ten women. Diagnosis often takes several years due to low awareness and menstrual stigma. In this study, we employed a social norm approach (SNA) to investigate the effects of an educational leaflet on endometriosis knowledge, menstrual stigma, and acceptance of paid menstrual leave among women and men. METHODS: The 3 × 2 online experiment tested the influence of either descriptive norm messages or both descriptive and injunctive norm messages (compared to a control group, factor 1) in an educational leaflet by taking the role of addressee's sex into account (quasi-experimental factor 2). The study included 796 German participants aged 16-35. RESULTS: Men exhibited significantly poorer knowledge, stronger menstrual stigma, and weaker policy acceptance compared to women. No significant main effect of the social norm messages on menstrual stigma was found. In contrast, the combined norm messages seem to be beneficial when addressing policy acceptance. Moreover, compared to the control group, the intervention material indirectly influenced stigma and policy acceptance through increased knowledge. CONCLUSIONS: Providing information about social norms appears to be an effective strategy for educating not only women but especially men about menstrual disorders like endometriosis.

Situational pathogen avoidance mediates the impact of social connectedness on preventive measures during the COVID-19 pandemic.

During the COVID-19 pandemic, physical distancing was one of the more important behaviours for reducing the spread of the virus. The present study investigated the influence on pathogen avoidance of familiarity with other people at private gatherings. Based on the social identity model of risk taking and the theory of the behavioural immune system, we assumed that greater familiarity with others would make people feel more connected with one another and decrease situational pathogen avoidance. This could result in lower perceptions of the risk of contracting COVID-19 and fewer protective behaviours. Two experiments (n1 = 1022, n2 = 994) showed that the negative influence of greater familiarity on the perceived risk of infection and protective behaviour is explained by an increased feeling of connectedness and less feeling of situational pathogen avoidance. In an additional survey, the participants (n = 23,023) rated the quality of their past social contacts. The correlational analyses showed that the familiarity of the other person was more important in explaining variance in protective behaviours than attitudes toward those behaviours or the pandemic situation itself. Understanding the process that result in an explosive increase in infection after social gatherings can improve infection control in the future.

Attitude toward a mandatory COVID-19 vaccination policy and its determinants: Evidence from serial cross-sectional surveys conducted throughout the pandemic in Germany.

BACKGROUND: Mandating vaccination against COVID-19 is often discussed as a means to counter low vaccine uptake. Beyond the potential legal, ethical, and psychological concerns, a successful implementation also needs to consider citizens' support for such a policy. Public attitudes toward vaccination mandates and their determinants might differ over time and, hence, should be monitored. METHODS: Between April 2020 and April 2021, we investigated public support for mandatory vaccination policies in Germany and examined individual correlates, such as vaccination intentions, confidence in vaccine safety, and perceived collective responsibility, using a series of cross-sectional, quota-representative surveys (overall N = 27,509). RESULTS: Support for a vaccination mandate declined before the approval of the first vaccine against COVID-19 in December 2020 and increased afterwards. However, at the end of April 2021, only half of respondents were in favor of mandatory regulations. In general, mandates were endorsed by those who considered the vaccines to be safe, anticipated practical barriers, and felt responsible for the collective. On the contrary, perceiving vaccination as unnecessary and weighing the benefits and risks of vaccination was related to lower support. Older individuals and males more often endorsed vaccination mandates than did younger participants and females. Interestingly, there was a gap between vaccination intentions and support for mandates, showing that the attitude toward mandatory vaccination was not only determined by vaccination-related factors such as vaccine safety or prosocial considerations. CONCLUSIONS: Because of low public support, mandatory vaccination against COVID-19 should be considered a measure of last resort in Germany. However, if removing barriers to vaccination and educational campaigns about vaccine safety and the societal benefits of high vaccination uptake are not sufficient for increasing vaccination uptake to the required levels, mandates could be introduced. In this case, measures to ensure and increase acceptance and adherence should be taken.

Emotional Situation of Children and Adolescents during the COVID-19 Pandemic in Germany: Results from the COVID-19 Snapshot Monitoring Study (COSMO).

The COVID-19 pandemic led to numerous restrictions in daily life that had a significant impact on the well-being and mental health of the population. Among others, children and adolescents were particularly affected, being a vulnerable group at risk. The aim of this study was to assess the emotional situation of children and adolescents during different phases of the pandemic and to identify modifying factors. Data from the serial cross-sectional COVID-19 Snapshot Monitoring (COSMO) survey in Germany were used for this study. The survey waves 12 (19th/20th May 2020) and 21 (15th/16th September 2020) were investigated as examples of two different pandemic phases. The psychosocial and emotional situation and well-being of children were measured with the emotional subscale of the Strengths and Difficulties Questionnaire (SDQ) assessed by parents. Descriptive analyses and logistic regressions were calculated. In total, a third of the participating parents in wave 12 and in wave 21 reported having children and adolescents with emotional symptoms. Especially children with younger parents seemed to be more affected by emotional symptoms. Sociodemographic aspects, such as household language, showed a significant association with reported emotional symptoms in children (Wave 12: OR = 2.22; 95% CI: 1.20-4.09). Reported prevalences of emotional symptoms in children did not differ between the pandemic phases. In conclusion, the pandemic had negative influences on the emotional symptoms of children and adolescents in COVID-19 pandemic waves in 2020, indicating a forecasted reoccurrence and need for preventive measures for upcoming waves and other pandemics in the future.

Good night: Experimental evidence that nighttime curfews may fuel disease dynamics by increasing contact density.

BACKGROUND: Nighttime curfews have been discussed and implemented in many countries as a means of controlling the COVID-19 pandemic. However, there is evidence that such curfews have little or no effect on disease dynamics when other measures such as bans on gatherings or business and school closures are already in place. There are two possible explanations for this. First, nighttime curfews may elicit reactance-a feeling of anger that drives non-adherence; second, nighttime curfews may motivate people to shift activities from night to daytime, thereby increasing contact density. METHODS: A survey experiment was conducted with German participants (N = 997) to investigate public perceptions of nighttime curfews and possible detrimental effects on contact behaviors. RESULTS: Most participants perceived nighttime curfews as ineffective. The introduction of a hypothetical curfew did not affect intentions to reduce private contacts but instead elicited reactance, motivating participants to violate curfew hours or to shift a fictitious dinner meeting to an earlier time rather than cancelling it. CONCLUSIONS: When people do not support nighttime curfews or do not understand the rationale behind them, introduction of this measure may fuel the spread of the disease. For that reason, nighttime curfews should be a measure of last resort and should be accompanied by a public communication campaign explaining the importance of contact reduction during both nighttime and daylight hours.

School opening during the SARS-CoV-2 pandemic: Public acceptance of wearing fabric masks in class.

OBJECTIVES: Policy decisions regarding mask wearing in schools in times of the SARS-CoV-2 pandemic will likely be made despite a lack of scientific data. Public acceptance is therefore an important indicator to inform the communication activities that accompany the introduction of a new policy. The goal was to assess acceptance and relevant target groups for communication activities. STUDY DESIGN: Cross-sectional online survey embedded in the regular German COVID-19 monitoring. METHODS: Besides sociodemographic information, trust in institutions, knowledge about COVID-19 and protective behaviors, as well as risk perceptions, we assessed public acceptance of school-related mask policies of parents and non-parents (total N â€‹= â€‹957). RESULTS: In the absence of mandatory mask policies in schools in Germany in August 2020, the general agreement with mask wearing in school was low. Those living in bigger cities or communities - where class sizes are usually larger - agreed more with mask wearing in class; those who felt a greater risk, had greater trust in institutions, or felt higher self-efficacy in fighting the outbreak also wanted children to wear a mask in class. Women were more likely than men to disagree with mask wearing in class. Agreement was highest that policies should uniformly apply for all institutions within a state/province and should not be regulated at the school level or federal/country level. CONCLUSIONS: Implementing mask policies in school will require intense communication. Acceptance of these policies from teachers and pupils should be considered as well. Women seem to be an important target group as they supported mask wearing in class less than men. Women's roles in controlling infectious diseases in school should therefore receive special attention and support.

Decreasing vaccine hesitancy with extended health knowledge: Evidence from a longitudinal randomized controlled trial.

This study assesses whether combining information about diseases and sequelae supports learning about disease risks and influences related health behavior (vaccination). OBJECTIVE: To test whether extending knowledge about the risks of primary diseases (e.g., influenza) with causally linked secondary diseases (sequelae such as sepsis) can decrease vaccine hesitancy in older adults, who are especially vulnerable to primary and secondary diseases. METHOD: In a preregistered longitudinal online experiment, 585 German participants > 60 years of age were randomly assigned to a 3 (time: before and after leaflet presentation, 3-month follow-up; within) × 3 (educational leaflet type: sepsis leaflet, traditional vaccination leaflet, and control leaflet; between) mixed-measurements design. The assessed outcomes were knowledge about influenza, pneumococci, and sepsis; risk perceptions; and immediate and long-term vaccination intention and behavior for pneumococcal and influenza vaccinations. RESULTS: The sepsis leaflet immediately increased the knowledge about influenza (effect size, η² = .080), pneumococci (η² = .071) and sepsis (η² = .113), risk perceptions (η² = .007), and intentions for both vaccinations (both η² = .015). Behavior during the follow-up did not differ between the conditions. Additional mediation analysis showed that increased knowledge immediately after the experiment predicted increased risk perceptions and intentions 3 months later (binfluenza = .060; bpneumococci = .055). CONCLUSION: Because immediate increases in knowledge and risk perceptions did not change behavior in the long term, extended knowledge interventions might be more effective in locations where positive intention can directly turn into action, such as doctors' clinics. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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

BACKGROUND: Pregnant women are at high risk for severe influenza. However, maternal influenza vaccination uptake in most World Health Organization (WHO) European Region countries remains low, despite the presence of widespread national recommendations. An influenza vaccination reduces influenza-associated morbidity and mortality in pregnancy, as well as providing newborns with protection in their first months. Potential determinants of vaccine hesitancy need to be identified to develop strategies that can increase vaccine acceptance and uptake among pregnant women. The primary objective of the systematic review is to identify the individual determinants of influenza vaccine hesitancy among pregnant women in Europe, and how to overcome the hesitancy. METHODS: Databases were searched for peer-reviewed qualitative and quantitative studies published between 2009 and 2019 inclusive. Databases included PubMed via MEDLINE, Cochrane Central Register for Controlled Trials, PsycINFO, SAGE Journals, Taylor and Francis and Springer nature. These covered themes including psychology, medicine, and public health. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach, 11 studies were eligible and analyzed for significant determinants of influenza vaccine hesitancy among pregnant women in Europe. RESULTS: The most commonly reported factors were psychological aspects, for example concerns about safety and risks to mother and child, or general low risk perception of becoming ill from influenza. Doubts about the effectiveness of the vaccine and a lack of knowledge about this topic were further factors. There was also influence of contextual factors, such as healthcare workers not providing adequate knowledge about the influenza vaccine or the pregnant lady stating their antivaccine sentiment. CONCLUSION: Health promotion that specifically increases knowledge among pregnant women about influenza and vaccination is important, supporting a valid risk judgment by the pregnant lady. The development of new information strategies for dialogue between healthcare providers and pregnant women should form part of this strategy.