The evolution of vaccine hesitancy through the COVID-19 pandemic: A semi-structured interview study on booster and bivalent doses.

We sought in-depth understanding on the evolution of factors influencing COVID-19 booster dose and bivalent vaccine hesitancy in a longitudinal semi-structured interview-based qualitative study. Serial interviews were conducted between July 25th and September 1st, 2022 (Phase I: univalent booster dose availability), and between November 21st, 2022 and January 11th, 2023 (Phase II: bivalent vaccine availability). Adults (≥18 years) in Canada who had received an initial primary series and had not received a COVID-19 booster dose were eligible for Phase I, and subsequently invited to participate in Phase II. Twenty-two of twenty-three (96%) participants completed interviews for both phases (45 interviews). Nearly half of participants identified as a woman (n = 11), the median age was 37 years (interquartile range: 32-48), and most participants were employed full-time (n = 12); no participant reported needing to vaccinate (with a primary series) for their workplace. No participant reported having received a COVID-19 booster dose at the time of their interview in Phase II. Three themes relating to the development of hesitancy toward continued vaccination against COVID-19 were identified: 1) effectiveness (frequency concerns; infection despite vaccination); 2) necessity (less threatening, low urgency, alternate protective measures); and 3) information (need for data, contradiction and confusion, lack of trust, decreased motivation). The data from interviews with individuals who had not received a COVID-19 booster dose or bivalent vaccine despite having received a primary series of COVID-19 vaccines highlights actionable targets to address vaccine hesitancy and improve public health literacy.

Intersecting Inequities in COVID-19 Vaccination: A Discourse Analysis of Information Use and Decision-Making Among Ethnically Diverse Parents in Canada.

BACKGROUND: Little is known about how intersecting social privilege and disadvantage contribute to inequities in COVID-19 information use and vaccine access. This study explored how social inequities intersect to shape access to and use of COVID-19 information and vaccines among parents in Canada. METHODS: We conducted semi-structured interviews on COVID-19 vaccination information use with ethnically diverse parents of children ages 11 to 18 years from April to August 2022. We purposefully invited parents from respondents to a national online survey to ensure representation across diverse intersecting social identities. Five researchers coded transcripts in NVivo using a discourse analysis approach informed by intersectionality. Our analysis focused on use of vaccine information and intersecting privileges and oppressions, including identifying with equity-denied group(s). RESULTS: Interview participants (N = 48) identified as ethnically diverse non-Indigenous (n = 40) and Indigenous (n = 8) Peoples from seven Canadian provinces. Racialized minority or Indigenous participants reflected on historical and contemporary events of racism from government and medical institutions as barriers to trust and access to COVID-19 information, vaccines, and the Canadian healthcare system. Participants with privileged social locations showed greater comfort in resisting public health measures. Despite the urgency to receive COVID-19 vaccines, information gaps and transportation barriers delayed vaccination among some participants living with chronic medical conditions. CONCLUSION: Historicization of colonialism and ongoing events of racism are a major barrier to trusting public health information. Fostering partnerships with trusted leaders and/or healthcare workers from racialized communities may help rebuild trust. Healthcare systems need to continuously implement strategies to restore trust with Indigenous and racialized populations.

Factors affecting hesitancy toward COVID-19 vaccine booster doses in Canada: a cross-national survey.

OBJECTIVE: COVID-19 transmission, emergence of variants of concern, and weakened immunity have led to recommended vaccine booster doses for COVID-19. Vaccine hesitancy challenges broad immunization coverage. We deployed a cross-national survey to investigate knowledge, beliefs, and behaviours toward continued COVID-19 vaccination. METHODS: We administered a national, cross-sectional online survey among adults in Canada between March 16 and March 26, 2022. We utilized descriptive statistics to summarize our sample, and tested for demographic differences, perceptions of vaccine effectiveness, recommended doses, and trust in decisions, using the Rao-Scott correction for weighted chi-squared tests. Multivariable logistic regression was adjusted for relevant covariates to identify sociodemographic factors and beliefs associated with vaccine hesitancy. RESULTS: We collected 2202 completed questionnaires. Lower education status (high school: odds ratio (OR) 1.90, 95% confidence interval (CI) 1.29, 2.81) and having children (OR 1.89, CI 1.39, 2.57) were associated with increased odds of experiencing hesitancy toward a booster dose, while higher income ($100,000-$149,999: OR 0.60, CI 0.39, 0.91; $150,000 or more: OR 0.49, CI 0.29, 0.82) was associated with decreased odds. Disbelief in vaccine effectiveness (against infection: OR 3.69, CI 1.98, 6.90; serious illness: OR 3.15, CI 1.69, 5.86), disagreeing with government decision-making (somewhat disagree: OR 2.70, CI 1.38, 5.29; strongly disagree: OR 4.62, CI 2.20, 9.7), and beliefs in over-vaccinating (OR 2.07, CI 1.53, 2.80) were found associated with booster dose hesitancy. CONCLUSION: COVID-19 vaccine hesitancy may develop or increase regarding subsequent vaccines. Our findings indicate factors to consider when targeting vaccine-hesitant populations.

RéSUMé: OBJECTIF: La transmission de la COVID-19, l'émergence de variants préoccupants et l'affaiblissement de l'immunité ont conduit à recommander des doses de rappel de vaccin contre la COVID-19. L'hésitation à la vaccination remet en question une large couverture vaccinale. Nous avons déployé une enquête transnationale pour étudier les connaissances, les croyances et les comportements en faveur de la poursuite de la vaccination contre la COVID-19. MéTHODES: Nous avons mené une enquête nationale transversale en ligne auprès d'adultes au Canada, entre le 16 et le 26 mars 2022. Nous avons utilisé des statistiques descriptives pour résumer notre échantillon et testé les différences démographiques, les perceptions de l'efficacité des vaccins, les doses recommandées et la confiance dans les décisions, en utilisant la correction de Rao-Scott pour les tests du chi carré pondérés. La régression logistique multivariée a été ajustée pour les covariables pertinentes afin d'identifier les facteurs sociodémographiques et les croyances associés à l'hésitation à la vaccination. RéSULTATS: Nous avons collecté 2 202 questionnaires remplis. Un faible niveau d'éducation (lycée : rapport de cotes (OR) 1,90, intervalle de confiance (IC) à 95% 1,29, 2,81) et le fait d'avoir des enfants (OR 1,89, IC 1,39, 2,57) étaient associés à une probabilité accrue d'éprouver une hésitation à l'égard d'une dose de rappel, tandis qu'un revenu plus élevé (100 000 $­149 999 $ : OR 0,60, IC 0,39, 0,91; 150 000 $ ou plus : OR 0,49, IC 0,29, 0,82) était associé à une diminution des probabilités. Incrédulité dans l'efficacité du vaccin (contre l'infection : OR 3,69, IC 1,98, 6,90; maladie grave : OR 3,15, IC 1,69, 5,86), en désaccord avec la prise de décision du gouvernement (plutôt en désaccord : OR 2,70, IC 1,38, 5,29; fortement en désaccord : OR 4,62, IC 2,20, 9,7) et la croyance dans le sur-vaccination (OR 2,07, IC 1,53, 2,80) ont été associées à une hésitation à recevoir une dose de rappel. CONCLUSION: Une hésitation à l'égard du vaccin contre la COVID-19 peut se développer ou augmenter à l'égard des vaccins ultérieurs. Nos résultats indiquent des facteurs à prendre en compte lors du ciblage des populations hésitantes à la vaccination.

A qualitative investigation of facilitators and barriers to accessing COVID-19 vaccines among Racialized and Indigenous Peoples in Canada.

Structural and systemic inequalities can contribute to susceptibility to COVID-19 disease and limited access to vaccines. Recognizing that Racialized and Indigenous Peoples may experience unique barriers to COVID-19 vaccination, this study explored early COVID-19 vaccine accessibility, including barriers and potential solutions to vaccine access, for these communities in Canada. We conducted semi-structured interviews about challenges to accessing COVID-19 vaccination with Racialized and Indigenous Peoples, including linguistic minorities and newcomers, in Spring 2021, just as COVID-19 vaccines were becoming more widely available in Canada. Participants were purposely selected from respondents to a Canadian national online survey. Three researchers analyzed the interviews for emergent themes using a descriptive content analysis approach in NVivo. At the time of the interview, interview participants (N = 27) intended to receive (n = 15) or had received (n = 11) at least one vaccine dose, or did not state their status (n = 1). Participants described multiple barriers to COVID-19 vaccination that they personally experienced and/or anticipated they or others could experience - including technology requirements, language barriers, lack of identification documentation, and travel challenges - as well as related solutions. These were organized into three broad categories: 1) COVID-19 disease and vaccination information, 2) vaccination booking procedures, and 3) vaccination sites. These structural and systemic barriers during the initial months of vaccine rollout substantially restricted participants' COVID-19 vaccination access, even when they were eager to get vaccinated, and should be addressed early in vaccine rollouts to facilitate optimal uptake for everyone everywhere.

"We need to protect each other": COVID-19 vaccination intentions and concerns among Racialized minority and Indigenous Peoples in Canada.

People may choose to receive vaccines in response to pressures that outweigh any concerns that they have. We explored Racialized minority and Indigenous Peoples' motivations for, perceptions of choice in, and concerns about, COVID-19 vaccination. We used a sequential explanatory mixed methods approach, including a national survey administered around the time vaccines were first authorized (Dec 2020) followed by qualitative interviews when vaccines were becoming more readily available to adults (May-June 2021). We analyzed survey data using descriptive statistics and interviews using critical feminist methodologies. Survey respondents self-identified as a Racialized minority (n = 1488) or Indigenous (n = 342), of which 71.4% and 64.6%, respectively, intended to receive a COVID-19 vaccine. Quantitative results indicated perceptions of COVID-19 disease were associated with vaccination intention. For instance, intention was associated with agreement that COVID-19 disease is severe, risk of becoming sick is great, COVID-19 vaccination is necessary, and vaccines available in Canada will be safe (p < 0.001). COVID-19 vaccines were in short supply in Canada when we subsequently completed qualitative interviews with a subset of Racialized minority (n = 17) and Indigenous (n = 10) survey respondents. We coded interview transcripts around three emergent themes relating to governmentality and cultural approaches to intersectional risk theories: feelings of collective responsibility, choice as privilege, and remaining uncertainties about COVID-19 vaccines. For example, some mentioned the responsibility and privilege to receive a vaccine earlier than those living outside of Canada. Some felt constraints on their freedom to choose to receive or refuse a vaccine from intersecting oppressions or their health status. Although all participants intended to get vaccinated, many mentioned uncertainties about the safety and effectiveness of COVID-19 vaccination. Survey respondents and interview participants demonstrated nuanced associations of vaccine acceptance and hesitancy shaped by perspectives of vaccine-related risks, symbolic associations of vaccines with hope, and intersecting social privileges and inequities (including racialization).

Understanding the Influence of Web-Based Information, Misinformation, Disinformation, and Reinformation on COVID-19 Vaccine Acceptance: Protocol for a Multicomponent Study.

BACKGROUND: The COVID-19 pandemic has generated an explosion in the amount of information shared on the internet, including false and misleading information on SARS-CoV-2 and recommended protective behaviors. Prior to the pandemic, web-based misinformation and disinformation were already identified as having an impact on people's decision to refuse or delay recommended vaccination for themselves or their children. OBJECTIVE: The overall aims of our study are to better understand the influence of web-based misinformation and disinformation on COVID-19 vaccine decisions and investigate potential solutions to reduce the impact of web-based misinformation and disinformation about vaccines. METHODS: Based on different research approaches, the study will involve (1) the use of artificial intelligence techniques, (2) a web-based survey, (3) interviews, and (4) a scoping review and an environmental scan of the literature. RESULTS: As of September 1, 2022, data collection has been completed for all objectives. The analysis is being conducted, and results should be disseminated in the upcoming months. CONCLUSIONS: The findings from this study will help with understanding the underlying determinants of vaccine hesitancy among Canadian individuals and identifying effective, tailored interventions to improve vaccine acceptance among them. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/41012.

Vaccine regulation should require and enforce the inclusion of pregnant and breastfeeding women in prelicensure clinical trials.

Exclusion of pregnant and breastfeeding women from the pivotal randomized controlled trials for COVID-19 vaccines that led to emergency regulatory approval created gaps in data needed for vaccine policy, healthcare provider recommendations, and women's decisions about vaccination. We argue that such knowledge gaps increase potential for vaccine hesitancy and misinformation relating to the health of women and infants, and that these gaps in evidence are avoidable. Over several decades, ethical and scientific guidance, scholarship, and advocacy in favor of pregnant and breastfeeding women's participation in clinical development of vaccines has accumulated. Guidance on how to include pregnant and breastfeeding women in vaccine trials ethically and safely predates the COVID-19 pandemic but has yet to be routinely incorporated in vaccine development. We highlight the important role regulatory authorities could play in requiring that pregnant and breastfeeding women be eligible as volunteer participants in prelicensure vaccine trials for products that are expected to be used in this population. Inclusion of pregnant and breastfeeding populations in clinical trials leading to market approval or emergency use authorization should be undertaken early or concurrently at the time of trials in the general population.

"I don't think there's a point for me to discuss it with my patients": exploring health care providers' views and behaviours regarding COVID-19 vaccination.

BACKGROUND: Health care providers' knowledge and attitudes about vaccines are important determinants of their own vaccine uptake, their intention to recommend vaccines, and their patients' vaccine uptake. This qualitative study' objective was to better understand health care providers' vaccination decisions, their views on barriers to COVID-19 vaccine acceptance and proposed solutions, their opinions on vaccine policies, and their perceived role in discussing COVID-19 vaccination with patients. METHODS: Semi-structured interviews on perceptions of COVID-19 vaccines were conducted with Canadian health care providers (N = 14) in spring 2021. A qualitative thematic analysis using NVivo was conducted. RESULTS: Participants had positive attitudes toward vaccination and were vaccinated against COVID-19 or intended to do so once eligible (two delayed their first dose). Only two were actively promoting COVID-19 vaccination to their patients; others either avoided discussing the topic or only provided answers when asked questions. Participants' proposed solutions to enhance COVID-19 vaccine uptake in the public were in relation to access to vaccination services, information in multiple languages, and community outreach. Most participants were in favor of mandatory vaccination policies and had mixed views on the potential impact of the Canadian vaccine-injury support program. CONCLUSIONS: While health care providers are recognized as a key source of information regarding vaccines, participants in our study did not consider it their role to provide advice on COVID-19 vaccination. This is a missed opportunity that could be avoided by ensuring health care providers have the tools and training to feel confident in engaging in vaccine discussions with their patients.

Deferring Risk: Limitations to the Evidence in Product Labels for Vaccine Use in Pregnancy.

Background: The gaps in clinical trial evidence about vaccination in pregnancy have serious implications for health care worker and public misunderstandings. Contradictions between National Immunization Technical Advisory Group (NITAG) recommendations and regulatory product labeling information contribute to misinformation about vaccine safety and effectiveness. Methods: A mixed methods approach that included a stakeholder consensus decision-making workshop and a national survey of Canadian health care providers (HCPs). Results: We identified knowledge gaps and serious limitations concerning the information in vaccine product labels. Stakeholders were troubled that some HCPs rely on regulatory product labels to inform their decisions without knowing their limitations in content. Our survey showed that HCPs were uncertain about the purpose of product labels and the evidence contained in them. Over a third of respondents incorrectly thought that product labels and NITAG recommendations are based on the same evidence and that the information they contain is regularly updated. Conclusions: Applying social risk theories, we show how such gaps in information defer responsibility for decisions about disease risk and vaccine safety from regulatory agencies and vaccine manufacturers onto HCPs and their clients. This may be especially relevant for COVID-19 and other emerging vaccines that are initially authorized for conditional or emergency use, and especially in understudied populations such as pregnant people. More frequent updating and alignment of robust, unbiased, and independently reviewed clinical trial and postmarket safety and effectiveness evidence with NITAG recommendations would allay HCP and public misunderstandings.

Healthcare providers' interpretations of product labelling information developed through a consensus stakeholder approach.

BACKGROUND: The World Health Organization recommends immunization with inactivated influenza vaccine (IIV) and tetanus-diphtheria-acellular pertussis (Tdap) vaccine during pregnancy. Yet, product labelling information for IIV and Tdap sends a different message. In a previous study, we developed evidence-based statements about vaccination in pregnancy that could be included in product information. This study compares healthcare providers' perceptions of the revised statements to those currently used in vaccine product labelling information. METHODS: A 30-item online survey with qualitative and quantitative components was distributed to Canadian maternal healthcare providers via professional organizations and public health. Participants read excerpts from revised and existing IIV and Tdap product labelling information and answered questions about how they perceived the safety and effectiveness of the vaccines, whether they would recommend each vaccine during pregnancy, and which statements they preferred. RESULTS: From June to August 2018, 449 healthcare providers completed the survey, including physicians (45%), nurses (24%), midwives (27%) and others (5%). Most participants perceived the vaccines to be safe and effective based on the revised statements. Over twice as many participants said they would recommend the IIV and Tdap vaccines in pregnancy based on the revised rather than the existing statements (64% versus 21% for IIV and 63% versus 27% for Tdap). Most participants selected that the revised statements better explained the risks and benefits of vaccination in pregnancy (65% versus 21% for IIV; 51% versus 27% for Tdap). Qualitative comments highlighted the strengths of the revised statements and areas for improvement. CONCLUSIONS: The majority of participants demonstrated preferences for the revised IIV and Tdap product label statements over the existing statements. Comments suggested the revised statements include improvements to the evidence-base and readability. Involving stakeholders improved the development of product labelling information, but further improvement is needed to support the evidence-based use of vaccines in pregnancy.

Developing product label information to support evidence-informed use of vaccines in pregnancy.

BACKGROUND: Product labelling information describing the use of vaccines in pregnancy continues to contain cautionary language even after clinical and epidemiological evidence of safety becomes available. This language raises safety concerns among healthcare providers who may hesitate to recommend vaccines during pregnancy. PURPOSE: To develop clear evidence-based language about vaccine safety and effectiveness in pregnancy for inclusion in vaccine product labels. METHODS: We conducted a three-stage consensus-methods project with stakeholders, including: healthcare providers, vaccine regulators, industry representatives, and experts in public health, communication, law, ethics, and social sciences. Using qualitative and quantitative methods, we held a nominal group technique (NGT) meeting, followed by a Delphi survey, and then a consensus workshop with a subset of Delphi participants. We developed a methodological tool to analyse data for consensus. PRINCIPAL RESULTS: Stakeholders (N = 14) at the NGT meeting drafted product label statements for evaluation in the Delphi survey. Survey participants (N = 41) provided feedback on statements for five hypothetical vaccines. Workshop participants (N = 27) initiated discussions that demonstrated a lack of awareness that the regulatory purpose of product labels is to provide a scientific summary of product-specific pre-clinical and clinical trial data. Each stage of this project built on earlier stages until we achieved strong consensus on the language, structure, and types of data that stakeholders wanted to include in inactivated influenza vaccine (IIV) and tetanus-diphtheria-acellular pertussis (Tdap) vaccine product labels in Canada. CONCLUSIONS: The revised statements for IIV and Tdap aligned with workshop participants' goals that the product label be evidence-based, with a consistent structure and language that is easily understood by healthcare providers. Emergent methods uncovered stakeholder concerns about the regulatory purpose, content, and evidence used in product labels. Involving healthcare providers in the development and regular updating of product information could prevent interpretations of that information that contribute to vaccine hesitancy.

A clinical nursing rotation transforms medical students' interprofessional attitudes.

This study explores the extent to which a one-week nursing rotation for medical students changed the interprofessional attitudes of the participating nurses and students. Third-year medical students worked with nurses before starting clinical rotations. Pre- and post-experience surveys assessing perceptions of mutual respect, nurse-doctor roles, and interprofessional communication and teamwork were given to 55 nurses and 57 students. The surveys consisted of qualitative questions and a Likert scale questionnaire that was analyzed using qualitative and quantitative content analyses. The response rate was 51/57 (89%) students and 44/55 (80%) nurse preceptors. Nurses reported that students met nurses' expectations by displaying responsibility, respect, effective communication, and an understanding of nursing roles. Medical students' narratives demonstrated two significant changes. First, their views of nurses changed from that of physician helpers to that of collaborative patient-centred professionals. Second, they began defining nursing not by its tasks, but as a caring- and communication-centred profession. Responses to Likert-scaled questions showed significant differences corresponding to changes described in the narrative. A one-week immersive clinical nursing rotation for medical students was a transformative way of learning interprofessional competencies. Learning in an authentic workplace during a clinical rotation engendered mutual respect between nurses and future doctors. Students' view of the role of nurses changed from nurses working for doctors with patients, to working with doctors for patients.

"One of the greatest medical success stories:" Physicians and nurses' small stories about vaccine knowledge and anxieties.

In recent years, the Canadian province of Alberta experienced outbreaks of measles, mumps, pertussis, and influenza. Even so, the dominant cultural narrative maintains that vaccines are safe, effective, and necessary to maintain population health. Many vaccine supporters have expressed anxieties that stories contradicting this narrative have lowered herd immunity levels because they frighten the public into avoiding vaccination. As such, vaccine policies often emphasize educating parents and the public about the importance and safety of vaccination. These policies rely on health professionals to encourage vaccine uptake and assume that all professionals support vaccination. Health professionals, however, are socially positioned between vaccine experts (such as immunologists) and non-experts (the wider public). In this article, I discuss health professionals' anxieties about the potential risks associated with vaccination and with the limitations of Alberta's immunisation program. Specifically, I address the question: If medical knowledge overwhelmingly supports vaccination, then why do some professionals continue to question certain vaccines? To investigate this topic, I interviewed twenty-seven physicians and seven nurses. With stock images and small stories that interviewees shared about their vaccine anxieties, I challenge the common assumption that all health professionals support vaccines uncritically. All interviewees provided generic statements that supported vaccination and Alberta's immunisation program, but they expressed anxieties when I asked for details. I found that their anxieties reflected nuances that the culturally dominant vaccine narrative overlooks. Particularly, they critiqued the influence that pharmaceutical companies, the perceived newness of specific vaccines, and the limitations of medical knowledge and vaccine schedules.

A war over mental health professionalism: Scientology versus psychiatry.

Over 60 years ago, founder L. Ron Hubbard began what has become Scientology's greatest battle. Scientology emerged from Dianetics, which Hubbard hoped would replace the psychiatric profession. In this article, we discuss how Scientology attempted to position itself as a rival profession to psychiatry and the consequences of those attempts. Scientology's battle with psychiatry gained some success from the social conditions during which it emerged, but it continues in a time that has seen increasing success with various psychiatric treatments. As such, Scientology's direct influence on the psychiatric profession may be difficult to measure, but its actions have coincided with substantial challenges to psychiatry.

Medicine and spiritual healing within a region of Canada: preliminary findings concerning Christian Scientists' healthcare practices.

Christian Science is the largest and most recognized of various spiritual healing groups that encourage members to forgo or overcome the need for medicine. Even so, it appears that some Scientists occasionally use medicine. In this study, I argue that Scientists in one region of Canada respond to influences on their healthcare practices differently and follow a variety of healthcare practices. These practices range from refusing medically necessary treatment (which could potentially harm individuals' health) to making full use of the medical system. I base my findings primarily on interviews with eleven current members and one former Christian Scientist.