"Using behavioral insights to inform the COVID-19 vaccine response in Kosovo[1]: Population perceptions and interventions".

Objective: Understand population perceptions in Kosovo[1] regarding COVID-19 vaccination to inform the pandemic response. Methods: Five rounds of a cross-sectional survey in representative samples of adults during 2020-2021. Analysis includes descriptive statistics, hierarchical cluster analysis, segmentation and logistic regressions. Results: Self-reported intention to vaccinate increased after the introduction of COVID-19 vaccines in Kosovo.[1] In less than one year, vaccination intentions increased from 36% to 66% of those unvaccinated. Predictors for vaccine intentions included gender, age, trust in health authorities. Segmentation analysis identified population segments that had high vaccine nintentions but low uptake, informing messages and campaign initiatives designed to translate intentions into behavior. Conclusion: Identifying people's perceptions and behavior is essential to support evidence-based policy making, especially during outbreak response. Innovation: BI is an innovative focus of research in Kosovo [1] where little BI data had been collected prior, and provided a unique understanding of population views, attitudes and behaviors related to COVID-19. These findings were not only essential for an evidence-based pandemic response but also laid the foundation for future broad application of BI to inform interventions that seek to enable, support and promote health-related behaviurs in Kosovo[1].

Vaccination barriers and drivers in Romania: a focused ethnographic study.

BACKGROUND: In 2016-18, a large measles outbreak occurred in Romania identified by pockets of sub-optimally vaccinated population groups in the country. The aim of the current study was to gain insight into barriers and drivers from the experience of measles vaccination from the perspectives of caregivers and their providers. METHODS: Data were collected by non-participant observation of vaccination consultations and individual interviews with health workers and caregivers in eight Romanian clinics with high or low measles vaccination uptake. Romanian stakeholders were involved in all steps of the study. The findings of this study were discussed during a workshop with key stakeholders. RESULTS: Over 400 h of observation and 161 interviews were conducted. A clear difference was found between clinics with high and low measles vaccination uptake which indicates that being aware of and following recommended practices for both vaccination service delivery and conveying vaccine recommendations to caregivers may have an impact on vaccine uptake. Barriers identified were related to shortcomings in following recommended practices for vaccination consultations by health workers (e.g. correctly assessing contraindications or providing enough information to allow an informed decision). These observations were largely confirmed in interviews with caregivers and revealed significant knowledge gaps. CONCLUSIONS: The identification of key barriers provided an opportunity to design specific interventions to improve vaccination service delivery (e.g. mobile vaccination clinics, use of an electronic vaccination registry system for scheduling of appointments) and build capacity among health workers (e.g. guidance and supporting materials and training programmes).

Design and implementation of tailored intervention to increase vaccine acceptance in a Somali community in Stockholm, Sweden - based on the Tailoring Immunization Programmes approach.

Objectives: Sweden has had a high and stable vaccination coverage for measles-mumps-rubella (MMR) vaccine (>96%) through the national immunization program (NIP), but coverage rates highlight local pockets of lower vaccination coverage. This project addressed low MMR vaccine acceptance among parents in a Somali community, in Stockholm. The objective of the intervention was to increase vaccine confidence and MMR-vaccine uptake and also to inform practices addressing vaccine acceptance. Study design: This paper describes the design and implementation of a multi-component intervention based on the Tailoring Immunization Programmes (TIP) approach, developed by the WHO European Regional Office. Methods: The theoretical underpinning of TIP is the Capability, Opportunity, and Motivation Model (COM-B model) and Behaviour Change Wheel framework (BCW), adapted for vaccination. The COM-model was used to identify barriers and drivers to vaccination and intervention types. The TIP-phases described in this paper are: pre-TIP (planning), three succeeding TIP phases (situational analysis, formative research, intervention design) and the post-TIP phase (implementation). Results: The situation analysis and formative research revealed that parents feared the MMR vaccine due to autism or that their child would stop talking following vaccination, despite lack of scientific evidence for an association between autism and MMR vaccines. Barriers were linked to their associated COM-B factors and mapped to appropriate intervention types for two target groups: Somali parents and nurses at the Child Health Centres (CHC). Selected intervention types targeting parents were education, persuasion and modelling whereas education and training were selected for CHC nurses. The intervention activities included community engagement for parents, while the activities for nurses focused on improving encounters and dialogue with parents having low vaccine acceptance. Following the intervention design the activities were developed, pilot tested and implemented. Conclusion: This study confirm that the TIP approach is valuable for guiding a stepwise working process for a thorough understanding of barriers and drivers for MMR vaccination among parents in this Somali community. It facilitated the design of a theory and evidence-informed intervention targeting parents and nurses.

Population Perspectives on Impact of the COVID-19 Pandemic on Essential Health Services-Behavioral Insights from the Federation of Bosnia and Herzegovina.

The aim of this study was to analyze the impact of the COVID-19 pandemic on patterns of use of essential health services (EHS), health-seeking behaviors, and population health and wellbeing in the Federation of Bosnia and Herzegovina (FBiH) from the perspective of its adult population. A population-based survey was implemented in the FBiH in December 2020 on a sample of 1068 adults. Overall, 64% of respondents received care, significantly more being women (67% vs. 61%, p = 0.046), those with a chronic disease (CD) (75% vs. 65%, p < 0.001), and of an older age (58% in 18−34 vs. 67% in older, p = 0.031). These groups also postponed care more often (39% in 55+ vs. 31% in 18−34 years old, p = 0.01; 55% with CD vs. 31% without, p < 0.001; and 43% in females vs. 32% males, p < 0.001). Main reasons for postponing care were lack of available appointments and fear of infection. The presence of a CD was the strongest predictor of need, access, and disruptions of health care. Respondents reported increased expenses for medicines (40%) and health services (30%). The findings of the survey add user insights into EHS disruptions to existing health statistics and other data and may be used to inform strategies for mitigating the impact of COVID-19 on the disruption of health care services, strengthening health system preparedness and building resilience for future emergencies.

Psychological well-being during the COVID-19 pandemic in Italy assessed in a four-waves survey.

COVID-19 pandemic had a negative impact on the mental health and well-being (WB) of citizens. This cross-sectional study included 4 waves of data collection aimed at identifying profiles of individuals with different levels of WB. The study included a representative stratified sample of 10,013 respondents in Italy. The WHO 5-item well-being scale (WHO-5) was used for the assessment of WB. Different supervised machine learning approaches (multinomial logistic regression, partial least-square discriminant analysis-PLS-DA-, classification tree-CT-) were applied to identify individual characteristics with different WB scores, first in waves 1-2 and, subsequently, in waves 3 and 4. Forty-one percent of participants reported "Good WB", 30% "Poor WB", and 28% "Depression". Findings carried out using multinomial logistic regression show that Resilience was the most important variable able for discriminating the WB across all waves. Through the PLS-DA, Increased Unhealthy Behaviours proved to be the more important feature in the first two waves, while Financial Situation gained most relevance in the last two. COVID-19 Perceived Risk was relevant, but less than the other variables, across all waves. Interestingly, using the CT we were able to establish a cut-off for Resilience (equal to 4.5) that discriminated good WB with a probability of 65% in wave 4. Concluding, we found that COVID-19 had negative implications for WB. Governments should support evidence-based strategies considering factors that influence WB (i.e., Resilience, Perceived Risk, Healthy Behaviours, and Financial Situation).

Medical specialists' attitudes and practices towards childhood vaccination: a qualitative study in Armenia.

BACKGROUND: Childhood vaccination rates in Armenia are high. However, anecdotal evidence suggests that some health workers may advise against vaccination. The extent and reasons behind this are unknown. This study used the World Health Organization Tailoring Immunization Programmes approach to investigate medical specialists' vaccination practices. METHODS: Face-to-face interviews were conducted with 30 medical specialists (paediatricians, immunologists, neonatologists, neurologists, gynaecologists). Interviews explored their vaccination practices (recommending/administering), knowledge, attitudes and confidence. Data were analysed using the Framework approach and COM (Capability, Opportunity, Motivation) factors. FINDINGS: Medical specialists were routinely consulted by parents about vaccination. They engaged in conversations, even if they did not administer vaccinations and lacked expertise. Vaccination recommendation was "selective", influenced by their own vaccine hesitancy. Doctors administering vaccination used false contraindications to postpone vaccination. Multiple barriers and drivers to positive vaccination practices were evident, with differences between specialists administering/not administering vaccinations. Capability Drivers were knowledge of vaccination, vaccines, and vaccine-preventable diseases; with awareness and use of protocols for adverse events and contraindications (those with a vaccination role). Barriers were a lack of a detailed understanding of vaccination, vaccines, and vaccine-preventable diseases, especially amongst neonatologists and gynaecologists, and for HPV. Poor knowledge of adverse events and mixed knowledge of contraindications was evident, as was low confidence about conversations with parents declining vaccination. Opportunity Drivers were using "official" guidance and professional information and feeling protected by the Government of Armenia should an adverse event occur. Conversely, barriers were a reliance on media/social media without considering credibility, peers not recommending vaccination, increasing parent demands and not feeling protected by the Government. Motivation Drivers were seeing vaccination as their responsibility (those who administer vaccinations); and generally supporting vaccination. Barriers were vaccine hesitancy, some anti-vaccination sentiments amongst neonatologists and gynaecologists and not seeing vaccination as their role (those who do not administer vaccinations). CONCLUSIONS: Applying a theory-informed approach allowed us to identify critical issues and possible solutions. High vaccination coverage may disguise underlying issues, e.g. false contraindications. We addressed gaps in the literature, with our geographical focus and study of medical specialists advising parents on vaccination, a widely used practice in this sub-region.

Satisfaction with Health Care Services in the Adult Population of the Federation of Bosnia and Herzegovina during the COVID-19 Pandemic.

Background and Objectives: Patient satisfaction with health care can influence health care-seeking behavior in relation to both minor or major health problems or influence communication and compliance with medical advice, which is especially important in emergencies such as the COVID-19 pandemic. Thus, it is important to continually monitor patient satisfaction with provided care and their dynamics. The aim of this study was to assess patient satisfaction with health care during the COVID-19 pandemic in the adult population of the Federation of Bosnia and Herzegovina (FB&H) and compare it with levels of satisfaction in the same population before the COVID-19 pandemic. Materials and Methods: A representative, population-based survey was implemented in the adult population of the FB&H using the EUROPEP instrument, which measures satisfaction with health care using 23 items. The sample included 740 respondents who were 18 years or older residing in the FB&H and was implemented in December 2020. All data were collected using a system of online panels. The survey questions targeted the nine months from the beginning of the pandemic to the time of data collection, i.e., the period of March to December 2020. Results: The mean composite satisfaction score across all 23 items of the EUROPEP tool was 3.2 points in all age groups; the ceiling effect was 22% for the youngest respondents (18-34 years old), 23% for 35-54 years old, and 26% for the oldest group (55+), showing increasing satisfaction by age. The overall composite score for both females and males was 3.2. The ceiling effect was higher in those with chronic disease (29% vs. 23% in those without chronic disease). The composite mean score for respondents residing in rural vs. urban areas was 3.2 with a ceiling effect of 22% in rural and 24% in urban residents. When comparing mean composite scores surveyed at various points in time in the FB&H, it was found that the score increased from 3.3 to 3.5 between 2011 and 2017 and dropped again to 3.3 in this study. Despite these observations in the overall trends of satisfaction scores, we note that no statistically significant differences were observed between most of the single-item scores in the stratified analysis, pointing to the relative uniformity of satisfaction among the analyzed population subgroups. Conclusions: The rate of satisfaction with health care services in the FB&H was lower during the COVID-19 pandemic compared to 2011 and 2017. Furthermore, while an increasing trend in satisfaction with health care was observed in the FB&H during the years prior to 2020, the COVID-19 pandemic may have contributed to the reversal of this trend. It is important to further monitor the dynamics of patient satisfaction with health care, which could serve as a basis for planning, delivering, and maintaining quality services during the COVID-19 pandemic and other emergencies.

Ten considerations for effectively managing the COVID-19 transition.

Governments around the world have implemented measures to manage the transmission of coronavirus disease 2019 (COVID-19). While the majority of these measures are proving effective, they have a high social and economic cost, and response strategies are being adjusted. The World Health Organization (WHO) recommends that communities should have a voice, be informed and engaged, and participate in this transition phase. We propose ten considerations to support this principle: (1) implement a phased approach to a 'new normal'; (2) balance individual rights with the social good; (3) prioritise people at highest risk of negative consequences; (4) provide special support for healthcare workers and care staff; (5) build, strengthen and maintain trust; (6) enlist existing social norms and foster healthy new norms; (7) increase resilience and self-efficacy; (8) use clear and positive language; (9) anticipate and manage misinformation; and (10) engage with media outlets. The transition phase should also be informed by real-time data according to which governmental responses should be updated.

Barriers and drivers to adult vaccination among family physicians - Insights for tailoring the immunization program in Germany.

BACKGROUND: In Germany, vaccination gaps exist mainly among adolescents and adults. Family physicians (FPs) administer adult vaccines. FPs strongly influence the vaccination behavior and attitudes of their patients, so their own vaccination-related attitudes and behaviors are critical to achieve high vaccination coverage. The aim of this study was to identify determinants of FPs' own vaccination uptake and their recommendation behavior. METHOD: 700 FPs participated in a random sampled telephone survey. Respondents were interviewed in both their roles as vaccine recipients and vaccine providers. Thus, participants indicated their own vaccination status and recommendation behavior as primary outcomes. Primary determinants were the 5C psychological antecedents of vaccination. In addition, participants indicated demographic data and other barriers towards vaccination. Association between outcome and determinants were examined using logistic regression models. RESULTS: Around 60% of physicians reported to be vaccinated against influenza, pertussis and hepatitis B, and the majority claimed to recommend vaccines to patients. Own vaccination status was significantly associated with the recommendation of vaccines. Of the psychological determinants confidence in the safety of vaccines was associated with own vaccination and recommendation behavior. Collective responsibility, constraints and complacency were associated with own vaccination status. Being from western Germany and being a homeopathic FP were independently associated with lower own vaccination behavior. Vaccine shortages (52.5%) and cost coverage problems (25.6%) were reported frequently as system-related barriers. There was a perception that the National Immunization Technical Advisory Group was influenced by other interests (14.8%) and that people are vaccinated against too many diseases (8%). Around 40% had implemented an office-based reminder system. DISCUSSION: FPs' vaccination behaviors are associated with various psychological determinants and additional barriers. In particular, confidence can leverage FPs' vaccination behaviors. Promoting office-based reminder systems, reducing system-related barriers, and building trust in official recommendations are additional measures to improve adult vaccination in Germany.

Measles outbreak in Romania: understanding factors related to suboptimal vaccination uptake.

BACKGROUND: A large measles outbreak started in Romania in 2016. Current study aimed to (i) clarify who was affected by the outbreak, (ii) identify their barriers and drivers to vaccination and (iii) explore variation by population group. METHODS: This was a two-component study. Outbreak surveillance data for 6743 measles cases were reviewed to identify key characteristics. A survey was administered via telephone to 704 caregivers of measles cases (520 respondents) to explore capability, opportunity and motivation barriers to vaccination. Data were summarized descriptively for respondent characteristics and statements. Differences by population group (education, household income, ethnicity, setting and mobility) were explored using χ2 tests, Fisher's exact tests or regression models. RESULTS: Most cases were unvaccinated and lived in low coverage areas. Ethnic minorities were disproportionally affected. Most caregivers felt welcome at health facilities. Some were less satisfied with the waiting time and had found the vaccine out of stock. Not everybody knew that vaccines were free of charge. Less than half knew the child's next vaccination date, some had not been informed and did not know where to seek this information. Some said their peers did not vaccinate. Beliefs were generally supportive of vaccination; but many were concerned about vaccine safety and found they had not received good information about this. Conclusions varied greatly between minorities and less educated groups, compared with people with higher education levels. CONCLUSIONS: Identifying characteristics of the population affected and underlying factors can inform a strategy to avoid future outbreaks and further research to obtain deeper insights.

Identifying barriers and drivers to vaccination: A qualitative interview study with health workers in the Federation of Bosnia and Herzegovina.

BACKGROUND: Vaccination coverage in Bosnia and Herzegovina has been declining over recent years. A World Health Organization Tailoring Immunization Programmes (TIP) project is underway to gain insights into the underlying reasons for this, to develop tailored interventions. As part of TIP, this study aimed to investigate the views of health workers on their barriers and drivers to positive childhood vaccination practices. METHODS: Face-to-face qualitative interviews explored 38 health workers' views on vaccination coverage, their vaccination attitudes, and system, programme and institutional influences on their vaccination practices. The data were analysed using content analysis and organised by the COM (Capability, Opportunity and Motivation) factors. FINDINGS: Very few differences in barriers and drivers were evident between high and low coverage primary care centres or across different professional roles. Capability: Drivers included awareness of the risks of low vaccination coverage, regular use of the Rulebook and Order, knowledge of how to advise parents on mild side effects and recognition of the importance of good communication with parents. Key barriers were the use of false contraindications to postpone vacination and poor skills in tailoring communication with parents. Opportunity: Drivers were sufficient time for adminstering vaccination and good availability of vaccines. Several barriers were evident: lack of implementation of mandatory vaccination, no uniform recall and reminder system or system for detecting under-vaccinated children, staff shortages and lack of time to discuss vaccination with parents. MOTIVATION: Drivers were a belief in the value, safety and effectiveness of vaccination and seeing that they have an important role to play. Barriers were a tendency to blame external factors e.g. anti-vax movement and a fear of being blamed for adverse events. CONCLUSIONS: The study identified complex and inter-related barriers and drivers to health worker positive vaccination practices. These insights will now inform a process to identify and prioritize interventions.

Understanding vaccine acceptance and demand-and ways to increase them.

Vaccination saves millions of lives, and the World Health Organization (WHO) European Region celebrated record high coverage in 2018. Still, national or sub-national coverage is insufficient to stop the spread of vaccine-preventable diseases. Health authorities are increasingly aware of the need to prioritize the "demand" side of vaccination. Achieving high and equitable vaccination uptake in all population groups is not a quick-fix; it requires long-term investment in multifaceted interventions, informed by research with the target groups. The WHO focuses on both individual and context determinants of vaccination behaviours. Individual determinants include risk perceptions, (dis)trust and perceived constraints; insights from psychology help us understand these. Context determinants include social norms, socioeconomic status and education level, and the way health systems are designed, operate and are financed. The WHO recommends using a proven theoretical model to understand vaccination behaviours and has adapted the "COM­B model" for their Tailoring Immunization Programmes (TIP) approach. This adapted model is described in the article. Informed by insights into the factors affecting vaccination behaviours, interventions and policies can be planned to increase vaccination uptake. Some evidence exists on proven methods to do this. At the individual level, some interventions have been seen to increase vaccination uptake, and experimental studies have assessed how certain messages or actions affect vaccination perceptions. At the context level, there is more documentation for effective strategies, including those that focus on making vaccination the easy, convenient and default behaviour and that focus on the interaction between caregivers and health workers.

Towards equity in immunisation.

In the World Health Organization (WHO) European Region, differences in uptake rates of routine childhood immunisation persist within and among countries, with rates even falling in some areas. There has been a tendency among national programmes, policymakers and the media in recent years to attribute missed vaccinations to faltering demand or refusal among parents. However, evidence shows that the reasons for suboptimal coverage are multifactorial and include the social determinants of health. At the midpoint in the implementation of the European Vaccine Action Plan 2015-2020 (EVAP), national immunisation programmes should be aware that inequity may be a factor affecting their progress towards the EVAP immunisation targets. Social determinants of health, such as individual and household income and education, impact immunisation uptake as well as general health outcomes - even in high-income countries. One way to ensure optimal coverage is to make inequities in immunisation uptake visible by disaggregating immunisation coverage data and linking them with already available data sources of social determinants. This can serve as a starting point to identify and eliminate underlying structural causes of suboptimal uptake. The WHO Regional Office for Europe encourages countries to make the equitable delivery of vaccination a priority.

Tailoring immunisation programmes: Using behavioural insights to identify barriers and enablers to childhood immunisations in a Jewish community in London, UK.

INTRODUCTION: Due to regular vaccine preventable disease outbreaks and sub-optimal immunisation uptake in the London borough of Hackney, home to the largest Charedi Orthodox Jewish community in Europe, it was decided, in consultation with the community, to implement the WHO Tailoring Immunization Programmes approach (TIP). DESIGN: The WHO Tailoring Immunization Programmes (TIP) approach was used. TIP provides a framework based on behavioural insights methodology to identify populations susceptible to vaccine preventable diseases, diagnose supply and demand side barriers and enablers to vaccination and recommend evidence-informed responses to improve vaccination coverage. RESULTS: The results of the formative research and behavioural analysis challenged the assumption that a cultural or religious anti-vaccination sentiment existed within the community. Critical issues related to access to and convenience of immunisation services. Service providers in the area have challenges due to having to deliver immunisation services to the large numbers of children without additional resource. Where mothers were choosing to delay or refuse vaccinations their reasons were broadly similar to the wider population. The behavioural analysis identified potential categorisation of subgroups within the community enabling a more tailored approach to addressing concerns and meeting parents' needs. CONCLUSION: The TIP approach was an effective way of investigating factors linked to sub-optimal immunisation within the Charedi community. The use of behavioural insights enabled the categorisation of subgroups so that more targeted interventions could be developed. The comprehensive stakeholder engagement which is a key pillar of the TIP approach ensured a deeper understanding of the barriers and enablers to vaccination as well as increasing the level of ownership in the community. TIP should be considered as a useful approach to identify main facilitators and barriers to vaccination in communities with suboptimal immunisation uptake.