TITLE: Intent to Vaccinate Children Against COVID-19 by Caregiver Vaccination Status in Northeast Tennessee AUTHOR INFO Yordanos Tafesse MD1 tafesse@etsu.edu Olivia A. Sullivan, EMT, MPH1 sullivano@etsu.edu Samuel Pettyjohn, DrPH, MPH1 pettyjohns@etsu.edu 1 Center for Rural Health Research, East Tennessee State University, Johnson City, TN. Addressing vaccine hesitancy is crucial in mitigating the spread of the ongoing COVID-19 pandemic. Children are mostly asymptomatic or have milder symptoms of COVID-19 than adults, and thus may remain undiagnosed, allowing the disease to spread to a large number of people; they are also at a high risk of long-term morbidity from as-of-yet undetermined effects of “long COVID.” Therefore, this analysis sought to examine caregivers’ intent to have their children vaccinated against COVID-19 based on the caregivers’ vaccination status and the age of the children. Using a secondary dataset from a survey in Northeast Tennessee, researchers found a significant difference between vaccinated and unvaccinated caregivers in intent to vaccinate their children in all age groups. Among caregivers with vaccine-eligible (12+ years children), unvaccinated caregivers (n=16) were significantly more likely than vaccinated caregivers (n=71) to not have had their child vaccinated (X2=24, df=1, p=7.8x10-7). Among caregivers who had not yet had their children vaccinated, unvaccinated caregivers (n=23) were significantly more likely to indicate they would “definitely not” get their children vaccinated than vaccinated caregivers (n=76) among all age groups of children: 0-4 years (X2=7.8, df=1, p=5.1x10-3), 5-9 years (X2=28, df=1, p=1.4x10-7), 10-13 years (X2=30, df=1, p=3.6x10-8), and 14+ years (X2=16, df=1, p=6.1x10-5) (Figure 2). The percentage of caregivers indicating they would “definitely not” get their child vaccinated differed by age of children among vaccinated caregivers (X2=11, df=3, p=0.011) but not unvaccinated caregivers (X2=5.1, df=3, p=0.16). Limitations include a small number of unvaccinated caregivers in the sample and the inability to account for correlation in the data. These results corroborate other findings nationwide, and demonstrate the need to provide high-quality education to address vaccine hesitancy in Northeast Tennessee.

Studiens syfte var att ur ett socialt perspektiv utforska erfarenheter och konsekvenser som svensk vårdpersonal upplever efter de valt att inte vaccinera sig mot Covid-19. Speciellt fokus har riktats mot hur de upplever att valet påverkar deras välbefinnande och om de erfar arbetsrelaterade eller sociala konsekvenser av att välja bort vaccinet.  Elva semistrukturerade intervjuer genomfördes. Analysen baserades på en kvalitativ innehållsanalys som resulterade i tre kategorier och tretton underkategorier. Resultatet visar på olika konsekvenser och erfarenheter av att inte vaccinera sig mot Covid-19, som stigmatisering, polarisering, diskriminering och mobbing. Upplevelser beskrivs på individ- och gruppnivå, både på arbetsplatser och inom en social kontext. Resultatet visar även på att välbefinnandet har påverkats i både positiv och negativ riktning av att välja bort vaccinen. Denna studie visar att en sjukdomspreventiv intervention i form av massvaccination samtidigt kan inverka negativt på hälsofrämjande faktorer som välbefinnande och social trygghet för de som väljer att inte vaccinera sig.

This work addresses the underlying issues surrounding COVID-19 vaccine uptake in Hispanic and Latinx communities in the Northeast region of Tennessee. A qualitative, phenomenological research approach was used to conduct interviews and data from the interviews was used to inform a survey instrument. The interview guide in the qualitative phase of the study was based on the Health Belief Model (HBM) developed by Rosenstock (Rosenstock, 1974). A quantitative approach was then used by piloting the survey instrument in the study population. Common themes found through the interviews were: previous negative experience with COVID-19 vaccination, previous negative experience as a result of COVID-19 disease and being in a role of a caretaker that drove vaccination uptake. Most participants in the survey identified as women (81%) (n=13), received a COVID-19 vaccine (87%) (n=14), lived in a multi-generational household (53%) (n=9) and had private or employer healthcare insurance (69%) (n=11). Only 50% (n=7) of those who were vaccinated had received an updated booster vaccine, indicating a reduction in COVID-19 vaccine uptake after the initial vaccine doses. Future research is needed to identify and analyze factors related to the uptake of booster vaccines against COVID-19 to maintain immunity against COVID-19 and tailor outreach in Hispanic and Latinx communities.

Background: The Hispanic community has historically faced high rates of vaccine hesitancy when compared to their non-Hispanic white counterparts. This not only poses a threat to their individual health, but also to their community. In a population that is disproportionately affected by COVID-19 infections, it is critical to address vaccine uptake concerns to control the pandemic and prevent future spread of infections. Objective: This study aims to explore Spanish speakers' vaccination decisions and to explore whether improving health literacy would be an effective approach in increasing vaccination rates. The secondary objective is to describe the role of physicians in decreasing vaccination hesitancy within the Hispanic community. Methods: A review of literature was conducted using articles from 2000 to 2022 focusing on the relationship between the Hispanic community and vaccines, as well as the Hispanic community's health literacy levels. Multiple databases were utilized, and research included the effects of improving health literacy for the Hispanic community in the United States and reasons for vaccine hesitancy in the Hispanic population. From the literature review, 40 articles met the inclusion criteria and were used to determine whether improving health literacy is an effective avenue for increasing vaccination rates in the Hispanic community. Results: A gap of research exists examining the relationship between health literacy and vaccine hesitancy in the Hispanic populations. Studies suggest three main reasons for reduced vaccine uptake for Latinos: the lack of knowledge about vaccines, the need for provider recommendations, and the inability to access healthcare. The studies also ii identified different methodologies in improving both vaccine hesitancy and health literacy. Conclusions: Health literacy may be able to address each of the three main concerns for vaccine hesitancy in the Hispanic population. Thus, research in the future should explore the relationship between health literacy and vaccine hesitancy. Keywords: health literacy, Hispanic, vaccine, vaccine hesitancy

Vaccine prophylaxis can undoubtedly be classified among the most important medical discoveries of the last century. The World Health Organization estimates that each year vaccinations prevent between two and three million deaths. Despite vaccines’ safety and effectiveness, vaccine hesitancy, the delay or refusal of vaccines despite their availability, is a re-emerging issue in high income countries. In this thesis I examine this issue pre- and post-COVID-19 pandemic, investigating the main predictors of vaccine hesitancy and highlighting the cognitive processes involved in individual's decision-making. In the theoretical section, I rely on contributions from sociology, economics and public health studies to build a framework enlightening the most relevant predictors of vaccine acceptance, the perceived risk of infectious diseases and the trust in the vaccination process. Through recent development in cognitive sciences, I reframe the issue showing the importance of considering the way individuals perceive, process and retrieve information in developing an informed analysis of vaccine acceptance. In the first empirical chapter, I investigate whether it is possible to identify subgroups in the population characterized by different world-views based on different patterns of the relationship between perceived risk and trust measures. I further assess whether such partitioning hides different levels of vaccine acceptance and whether it also entails a mean of social stratification. In the second empirical chapter I further explore how certain cognitive processes, analytic and intuitive cognition, might be connected to a differential in vaccine acceptance. Furthermore, I highlight individuals’ qualitatively complex perceptions of risk, and I suggest how enhancing the attention on cognitive processes and affective concerns might be a key to addressing vaccine hesitancy. In the third empirical chapter, I investigate vaccine hesitancy during the COVID-19 pandemic. I exploit rich comparative longitudinal data and analyze the association between risk perceptions, trust, and willingness to be vaccinated at three different levels: between individuals, between countries and within countries over time. In this chapter, I underline the importance of disentangling the main relationships of this thesis at different levels of analysis, and stress that vaccine acceptance is a multifaceted topic that could involve issues far beyond its own boundaries.

Popular media portrayals and promotion of vaccine hesitancy still rely heavily on the information-deficit model despite a push for non-information-based strategies from scholars such as increasing trust. In this study, newspaper portrayals of vaccine hesitancy during the COVID- 19 pandemic were examined to determine the prevalence of the information-deficit model. Canadian newspaper articles from The Globe & Mail and the National Post published during a 14-month period between May 2020 and June 2021 were examined. A total of 56 unique articles were identified, and a coding frame was developed through both inductive and deductive methods. Data was collected using a qualitative content analysis. Through thematic analysis, three distinct portrayals of vaccine hesitancy were identified, and the use of the information- deficit model varied depending on the portrayal. Portrayals of vaccine hesitancy in the general population and vaccine hesitancy as “anti-vaxxers” used the most rhetoric based on the information-deficit model, whereas vaccine hesitancy portrayals focusing on specific marginalized subgroups included more non-information-based explanations and suggested solutions. Media portrayals of vaccine hesitancy show signs of shifting to a non-information- based rhetoric, but is still predominantly based on the information-deficit model. This reliance on the information-deficit model, as well as its possible effects on expert-lay relationships, are discussed.

Purpose: Parental decisions to vaccinate their children may be impacted by the advice of health care providers practicing complementary and alternative medicine (CAM). Available literature suggests an association between vaccine delay or refusal and CAM use, decreased vaccination status of naturopathic patients, and increased vaccine hesitancy among naturopathic students. Some naturopathic physicians state that their approach towards discussions about childhood vaccinations may support families in choosing partial vaccination over complete refusal, ultimately contributing to an overall increase in vaccinations. Methods: Using a modified Health Belief Model as a theoretical framework, this online survey of naturopathic physicians assessed childhood vaccine-related perceptions and practices. The survey instrument was developed through an iterative process using surveys from previous research, adapted by expert opinion and input from focus group participants. Results: Surveys were completed between October and November 2014 by 145 naturopathic physicians (response rate 28.7%) licensed and practicing in Vermont or Oregon State. The vast majority of respondents (93%) discuss childhood vaccines with their patients, and discussions may include numerous topics focused on assessing individualized risk factors and providing information to parents. Most (70%) assist parents in creating a customized vaccine schedule for their children, which may delay the start of vaccination until a later age, give select vaccines only, and/or spread out the vaccine schedule (as compared to the CDC-ACIP recommended schedule). Vaccine-specific safety concerns are highly prevalent (67%), vary by vaccine, and include concerns regarding vaccine schedule, necessity, risk for potential adverse effects, and safety of vaccine ingredients. The majority of respondents use a variety of approaches intended to reduce adverse effects of vaccination (91%) and to make childhood vaccination safer and more effective (93%). Finally, most respondents are in agreement with each other on key vaccination beliefs underscoring both concerns and the importance of childhood vaccinations. Conclusions: Results highlight an individualized approach towards childhood vaccinations by naturopathic physicians, often including a customized schedule and in-depth conversations with parents. The impact of this approach on parental vaccine choice and public health remains unknown. Results may promote further understanding of the various therapeutic recommendations and safety concerns regarding childhood vaccinations held by naturopathic physicians and can potentially foster more effective communication among all healthcare providers on this important public health issue.

Bakgrund: Vaccinationstäckning är ett av de viktigaste och mest kostnadseffektiva sättet att förbättra den globala folkhälsan. Trots det uppfattas vacciner som osäkert och onödigt av allt fler individer. Försämrad vaccinationstäckning påverkar flockimmuniteten med ökad risk för nya sjukdomsutbrott och epidemier. Syfte: Syftet var att undersöka och sammanställa den vetenskapliga litteraturen om vilka faktorer som påverkar vårdnadshavarnas beslut att vaccinera eller inte vaccinera sina barn mot mässling-påssjuka-röda hund (MPR). Metod: Systematisk litteraturöversikt där totalt tio vetenskapliga artiklar ligger till grund för resultatet. The Health Belief Model har använts som teoretisk utgångspunkt. Resultat: Flera faktorer var viktiga för föräldrars beslut om vaccination. Fem faktorer identifierades som påverkar föräldrar att inte vaccinera sina barn: att föredra naturlig immunisering, rädsla för biverkningar, rädsla för vaccinet, misstro till myndigheter och förebygga sjukdom genom livsstil. Fyra faktorer som påverkar föräldrar att låta vaccinera sina barn identifierades: att undvika sjukdom, värna om flockimmunitet, fördelar överväger nackdelar samt kunskap och information om sjukdomarna och vaccinet. I resultatet identifierades också ett bifynd, att låta barnets immunsystem mogna innan vaccination. Både föräldrar som vaccinerade och inte vaccinerade sina barn tyckte att det fanns för lite information om vaccinet och dess biverkningar. Slutsats: Flera faktorer påverkar föräldrars beslut om vaccination för sina barn mot MPR. Både föräldrar som vaccinerar och inte vaccinerar sina barn tycker informationen om vaccin och dess biverkningar är för knapphändig och svårtillgänglig. Det är viktigt som sjuksköterska att ha kunskap om vilka faktorer som påverkar föräldrars beslut för att kunna bemöta föräldrars oro och bistå med adekvat och evidensbaserad information. / Background: Vaccination coverage is one of the most important and cost-effective ways to improve global health. Despite this more and more people feel uncertain about vaccinations. Impaired vaccination coverage affects the herd immunity and leads to an increased risk of disease outbreaks and epidemics. Aim: The aim of this study was to examine which factors influence parents’ decisions regarding vaccination of their children against measles-mumps-rubella (MMR). Method: A systematic review where the result is based on ten scientific articles. The Health Belief Model was used as theoretical framework. Results: Several factors were important for the decision to vaccinate or not. Five factors were identified among parents not vaccinating: to prefer natural immunization, fear of side effects, fear of the vaccine, mistrust in the authorities and prevent disease through lifestyle. While four factors were identified among parents vaccinating: to prevent disease, to protect the herd immunity, the advantages outweigh disadvantages, and knowledge and information about the disease and the vaccine. In addition, the finding, to let the child's immune system mature before vaccination was identified. Both parents who accept vaccination and parents who decline vaccination of their children considered the information about the vaccine inadequate. Conclusion: Several factors influence parents’ decision regarding vaccination of their children against MMR. Both parents who accept vaccination and parents who decline vaccination of their children consider the information about the vaccine and its side effects too scant and difficult to access. It's important that nurses have knowledge about factors that influence parents' decisions in order to respond to their concerns and provide appropriate and evidence-based information.

Inledning: Trots ansträngningar från nationella och internationella myndigheter har följsamheten till det rekommenderade vaccinet mot mässling minskat. Detta har resulterat i ett ökat antal rapporterade fall av mässling i världen, vilket riskerar ha allvarliga konsekvenser för befolkningen. Syfte: Studiens syfte är att undersöka och sammanställa den vetenskapliga litteraturen om vilka faktorer som ligger bakom föräldrars beslut gällande att inte låta sina barn vaccineras mot mässling. Metod: Litteraturstudie med deskriptiv design. Systematiska sökningar genomfördes i databaserna Academic Search Elite, Cinahl & PubMed. Data analyserades och kategoriserades under fem teman. Resultat: De flesta av föräldrarna var ovetandes om riskerna med att drabbas av mässling och oroades istället över konsekvenserna av eventuella bieffekter till följd av vaccinet. Deras attityd till vaccinet var även starkt påverkad av deras individuella tro och livsstil, likväl deras sociala omgivning. Föräldrarna rapporterade även brist i tillförlitlig information samt en oförmåga att fatta informerade beslut. Diskussion: Bristen i överensstämmelse med aktuella riktlinjer för vaccination av små barn mot mässling är ett multifaktoriellt samhällsproblem och som varierar mellan olika befolkningsgrupper. Föreliggande studier understryker behovet av effektivare kommunikationsstrategier för att hjälpa föräldrar att förstå fördelarna med barnvaccination. / Introduction: Despite intense efforts made by national and international health authorities to promote the importance of measles vaccination, the prevalence of vaccinated children has been decreased.Aim: The aim of this study was to perform a systematic review of the scientific literature to describe the factors supporting parental decision to refuse childhood measles vaccination.Method: A systematic review of qualitative studies was conducted in the following databases: Academic Search Elite, Cinahl and PubMed. Data was analyzed and the results were classified into five categories. Result: Most parents were unaware of the risks connected to measles and were instead more concerned about the consequences of potential side effects of the vaccine. The parents’ attitude to vaccination was strongly influenced by their individual beliefs and lifestyle, as well as by the interaction with the social environment. The parents also reported a lack of reliable information and the consequent inability to take an informed decision.Discussion: The lack of compliance to the guidelines for the vaccination of young children against measles is influenced by factors varying between different population groups. Notably, this study highlighted the need for more effective communication strategies to help parents understand the advantages connected to children’s vaccination.

Bakgrund: Vaccinationer räknas till sjukvårdens mest effektiva hälsoåtgärd och räddar cirka 1.5 miljoner liv årligen. Trots möjligheten att utnyttja vaccin väljer somliga att inte vaccineras. Detta fenomen kallas för vaccintveksamhet är ett av de tio största hoten mot den globala folkhälsan. Syfte: Syftet var att beskriva vilka motiv som leder till att föräldrar är tveksamma till att vaccinera sina barn. Metod: En allmän litteraturstudie med en deskriptiv design genomfördes. En litteratursökning utfördes i databaserna Cinal och Pubmed, vilket resulterade i elva kvalitativa studier som var relevanta för denna studies syfte. Travelbees omvårdnadsteori användes som teoretisk referensram. Resultat: Resultaten från artiklarna presenterades i 6 olika teman: oro gällande vaccinets säkerhet, misstro till myndigheter, påverkan av social miljö och normer, naturlig immunisering och sjukdomars allvarlighetsgrad och hälsosam livsstil. Föräldrar ifrågasatte vaccinets säkerhet och upplevde otillräcklig information från myndigheter. En del påverkades av samhällets normer. Somliga ansåg att en naturlig immunisering var att föredra och en del trodde att sjukdomarna var ofarliga. Vissa ansåg att en hälsosam livsstil gav ett tillräckligt skydd mot sjukdomarna. Slutsats: Föräldrarnas tveksamhet till att vaccinera sina barn grundas huvudsakligen i en ofullständig förståelse för vaccinets säkerhet och effektivitet. Många kände misstro till sjukvården och föredrog naturlig immunisering framför vaccinering. Den ofullständiga förståelsen bottnade i många fall i informationsbrist och resulterade i att föräldrar kände oro inför vaccin. Sjuksköterskan har en viktig roll i att inta god handlingsberedskap och att i vårdmötet säkerställa att föräldrarna ges förutsättningar att förstå nyttan och nödvändigheten med vaccin. / Background: Vaccine is one of the most effective tools to prevent diseases and saves around 1,5 million lives yearly. Despite access to vaccines, some individuals choose to not vaccinate. This phenomenon known as vaccine hesitancy, is one of the ten biggest threats to global public health. Purpose: The purpose of this study was to describe the motives behind parents’ hesitancy to vaccinate their children. Method: A litterature study with a descriptive design was performed. A literature search was conducted using Cinahl and PubMed databases, leading to eleven qualitative studies relevant to the purpose of this study. Travelbee's nursing theory was used as a theoretical model. Results: The results from all articles are presented in six themes: Concerns regarding the vaccine’s safety, Distrust of authorities, Impact of social environment and norms, Natural immunization and disease severity and Healthy lifestyle. Parents questioned the safety of the vaccine and experienced lack of information from authorities. Some were influenced by norms of the society. Multiple parents considered that a natural immunization was preferable to the actual diseases. Several believed that a healthy lifestyle would provide enough protection against the diseases. Conclusion: Parents hesitancy to vaccinate their children are mainly based on an incomplete understanding of the vaccine's safety and effectiveness. The incomplete understanding was due to a lack of information which led parents to worry about the vaccine. The nurse has an important role in taking good action readiness and to ensure that parents are given the conditions to understand the benefit and necessity of the vaccine.