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.

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.

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.

Bakgrund: Vaccin är sjukvårdens viktigaste, mest kostnadseffektiva åtgärd som räddar två till tre miljoner liv per år världen över. Hög vaccintäckning skyddar inte bara individerna utan minskar spridningen av sjukdomar i samhället. Trots detta finns det personer som tvekar på dess effektivitet, säkerhet och nödvändighet. Dessa personer väljer att avstå från att vaccinera sina barn, vilket innebär en risk för individen och samhället. Syfte: Syftet var att beskriva vilka faktorer som gör föräldrar tveksamma till att vaccinera sina barn enligt deras nationella vaccinationsprogram. Metod: Litteraturstudie baserad på tio kvalitativa artiklar publicerade mellan år 2012 och 2019. Datainsamlingen utfördes i databasen PubMed och en sekundärsökning gjordes för att få ett så täckande resultat som möjligt. Den teoretiska referensramen för den här studien grundades på Leiningers transkulturella omvårdnadsteori. Resultat: Resultatet presenteras i fem olika teman: Allvarliga biverkningar och farliga tillsatser, Brist på information, Hälsosam livsstil och naturlig immunisering, Förtroende för myndigheter och Bristande kunskap om sjukdomar. Majoriteten av deltagarna var rädda för att vaccinet kunde skada deras friska barn. Det fanns även en misstanke om att sjukdomarna som vaccin skyddar mot inte är speciellt farliga och att myndigheter som rekommenderar vaccin har finansiellt motiverade avsikter. Hälsosamma levnadsvanor och naturlig uppbyggnad av immunförsvaret ansågs tillräckligt för att skydda ett barn genom livet. Slutsats: De huvudsakliga faktorerna till varför föräldrar tvekar inför att vaccinera sina barn grundar sig i bristande förståelse för vaccin och sjukdomarna det skyddar mot. Genom att skapa sig en förståelse av alla bakomliggande faktorer som påverkar vaccinets förtroende kan varje land skräddarsy insatser som ökar vaccintäckningen. / Background: Vaccine is the most important, cost effective healthcare action that saves two-three million lives each year all over the world. High coverage of vaccine not only protects the individuals but reduces the spread of diseases in the community. Still, there are people who doubt its effectiveness, safety and necessity. These people choose to refrain from getting their children vaccinated, which puts the individual and the society at risk. Purpose: The purpose was to describe what factors make parents hesitant to vaccinate their children according to their national vaccination programme. Method: Literature study based on ten qualitative articles published between 2012 and 2019. The data collection was carried out in the PubMed database and a secondary search was done to obtain as comprehensive result as possible. The theoretical framework of reference for this study was based on Leininger's transcultural nursing theory. Results: The results are presented in five different themes: Serious side effects and dangerous additives, Lack of information, Healthy lifestyle and natural immunization, Trust in authorities and Lack of knowledge about diseases. The majority of participants were afraid that the vaccine could harm their healthy children. There was also a suspicion that what the diseases vaccines protect against are not particularly dangerous and that the authorities recommending the vaccines have financially motivated intentions. Healthy living habits and natural enhancement of the immune system were considered sufficient to protect a child through life. Conclusion: The main factors to why parents hesitate to vaccinate their children are based on a lack of understanding about the vaccines and the diseases it protects against. By creating an understanding of all the factors affecting the confidence in vaccine, each country can tailor actions that increase vaccine coverage.

Bakgrund: Flera av världens länder samverkar för att uppnå hög vaccinationstäckning för att kunna kontrollera, eliminera och utrota allmänfarliga sjukdomar. Nationella barnvaccinationsprogram ses som en av de säkraste, mest kostnadseffektiva och framgångsrika interventionerna för att förebygga dödsfall och förbättra liv samtidigt som vaccintveksamhet ses som ett av de tio största hoten mot världshälsan. Syfte: Identifiera faktorer som ligger till grund för föräldrars tveksamhet inför vaccination av sina barn. Metod: En systematisk litteraturstudie där empirisk forskning analyserats och sammanställts. Sökningarna utfördes i två databaser, 19 artiklar inkluderades i litteraturstudien, 12 stycken kvantitativa och sju kvalitativa. Inkluderade artiklar är kvalitetsgranskade. Resultat: I litteraturstudiens resultat presenteras fyra huvudkategorier; Vaccinets verkan, Information, Förtroende samt Levnadsförhållanden och livsstilsval. Resultatet identifierar föräldrars oro för biverkningar och tveksamhet inför vaccinets effekt, sociodemografiska faktorer som påverkar vaccinationstäckningen samt en påverkan från religiös tro. Generellt uppgav föräldrar att det saknade information för att kunna ta beslut om att vaccinera sina barn eller inte. De saknade information om vaccinets innehåll samt engagemang i vårdpersonalens informationsöverföring. Slutsats: Vaccintveksamhet är ett komplext och mångsidigt fenomen. Oro och rädsla inför biverkningar från de olika vaccinerna kan bidra till ökad tveksamhet i beslutsprocessen hos föräldrar och en anledning till att avstå eller fördröja vaccination. Resultatet påvisar vikten av tillräcklig information för att trygga föräldrar i att vaccinera sina barn. Denna litteraturstudie ökar förståelsen inför föräldrars inställning till vaccination och ger en ökad förståelse för hur information om hälsofrämjande åtgärder tas emot av föräldrar. / Background: Several of the world’s countries work together to achieve high vaccination coverage in order to be able to control, eliminate and eradicate dangerous diseases. National childhood vaccination programs are seen as one of the safest, most cost-effective and successful interventions to prevent deaths and improve life while vaccine hesitancy are seen as one of the ten biggest threats to world health. Aim: Identify factors that underlie parents’ hesitation about vaccination their children. Method: A systematic literature review where empirical research has been analyzed and compiled. The searches were performed in two databases, 19 articles were included in the literature review, 12 were quantitative and seven qualitative. Included articles are quality reviewed. Results: In the result of the literature review, for main categories were presented; Vaccine Effect, Information, Confidence and Living Conditions and Lifestyle Choices. The result identify parents’ concerns about side effects and doubts about the vaccine’s effect, certain socio-demographic factors that affect vaccination coverage and also an influence from religious beliefs. In general, parents stated that they lacked sufficient information to be able to decide whether or not to vaccine their children. They laced information about the vaccine’s content and involvement in the healthcare workers information transfer, which led to their own information search on the internet. Conclusion: Vaccine hesitancy is a complex and versatile phenomenon. Anxiety and fear of side effects from the various vaccines can contribute to increased hesitation in the decision-making process in parents and a reason to abstain from or delay vaccination. This literature review increases the understanding of parent’s attitudes towards vaccination and provides an increased understanding of how information about health-promoting measures is received by parents.

Objective: Vaccine hesitancy remains a significant public health challenge, and one that is socially patterned. This study examined whether the vaccine hesitancy effects of identifying as female, race–ethnicity, the number of children, educational attainment, and political conservatism were mediated by governmental conspiracy beliefs. Methods: Linear mediation models controlling for potential confounders were employed to analyze data from a national survey of adults (2019 Chapman University Survey of American Fears; n = 1,209). Results: Effects on vaccine hesitancy were significant and negative for educational attainment, and significant and positive for the other focal predictors. Governmental conspiracy beliefs significantly mediated each of these effects; the percent mediated was largest for Hispanic identity (79 percent), followed by female identification (69 percent), educational attainment (69 percent), number of children (55 percent), black identification (34 percent), and political conservatism (30 percent). Conclusion: This study underscores the importance of nonvaccine-related conspiracy beliefs for future interventions aimed at reducing sociodemographic disparities in vaccine hesitancy.

Introduction: COVID-19 vaccination in the United States (U.S.) has stalled, with the lowest rates observed in the southern parts of the country. Vaccine hesitancy is a primary contributor to this trend, and health literacy (HL) has been identified as a potential determinant for hesitancy. This study aims to assess the association between HL and COVID-19 vaccine hesitancy in a population residing in 14 southern states of the U.S. Methods: We utilized a web-based survey conducted in U.S. southern states between February and June 2021 that yielded 417 total responses. The outcome was “vaccine hesitancy”. The main independent variable was HL, assessed by validated measures whose responses were aggregated to an HL index score and subsequently categorized as “low or moderate HL”, and “high HL”. Descriptive statistics were performed, and multivariable logistic regression analysis was conducted, controlling for sociodemographic and other variables. Results: Of the total respondents (n=247 after data cleaning), the overall rate of vaccine hesitancy was 22.3%. The rate of vaccine hesitancy was 10.9% and 89.1% for low/moderate and high levels of HL, respectively, but the association was not significant. However, personal perception of COVID-19 threat was significantly associated with lower odds of vaccine hesitancy versus those without perception of threat [adjusted odds ratio, AOR: 0.15; 95% CI: 0.03-0.73; p = 0.0186]. Similarly, obtaining information from public health sources was significantly associated with a lower likelihood of vaccine hesitancy [AOR:0.17; 95% CI: 0.05-0.61; p=0.0064]. Conclusion: HL was not a significant predictor of vaccine hesitancy in a population residing in southern states, suggesting that low rates of vaccination in the region may not be due to knowledge about COVID-19. Personal perception of COVID-19 threats and obtaining information from public health sources were associated with decreased vaccine hesitancy. This implies that we should strengthen public health communication infrastructure in the country. We also need to unpack the contextual factors that contribute to the disproportionately high rates of vaccine hesitancy in the region.

BACKGROUND: The widespread use of vaccines led to significant decline in multiple potentially fatal infectious diseases. Recently, there has been an increase in vaccine hesitancy. Measles and pertussis outbreaks throughout the United States have put a spotlight on this urgent healthcare issue. Motivational interviewing is a counseling tactic that is gaining popularity and is being studied for its efficacy in preventative medicine and psychological disorders. It aims to inspire people to make behavioral changes through collaborative relationships with their provider by understanding how current actions do not translate into their health goals. LITERATURE REVIEW FINDINGS: Vaccine hesitancy is growing. Communities with decreased immunization rates are associated with a higher risk of disease outbreak. Increasing rates of undervaccinated children are likely due to increases in non-medical exemptions. Many parents, regardless of their vaccine hesitancy status, are concerned about vaccine safety. Vaccine hesitant parents refuse vaccines due to philosophical and religious beliefs, conspiracy theories, and safety concerns. Parents feel that providers do not adequately address their concern. Providers report not having the training to discredit parental concerns. The majority of parents describe their child’s pediatrician as their most trusted source of vaccine information. Parents who receive vaccine information from a provider are more likely to comply with the recommended childhood vaccine schedule. The most efficient way to discuss vaccines with parents has yet to be determined. PROPOSED PROJECT: This is a proposed QI research project for the Pediatric Clinic at Boston Medical Center. Providers would be trained in motivational interviewing during several sessions that included lectures and small group practice sessions with systematic feedback. During the intervention, parents who refuse vaccines for their child, aged 0-6 years old, will receive motivational interviewing from the provider. The proportion of the vaccine hesitant parents who accept the offered vaccine after will be analyzed. The pre and post intervention vaccination rates for the entire clinic will also be assessed. Data collection will be preformed through retrospective chart review. The project aims to increase provider confidence on vaccine counseling, educate providers on reasons for hesitancy, and improve compliance with the CDC recommended vaccine schedule. CONCLUSION: While most Americans continue to vaccinate their children according to the CDC’s recommended schedule, constant vigilance is required to maintain high immunization rates to protect our communities. Motivational interviewing is goal-oriented to alter a specific behavior and would allow providers to engage in an open, persuasive dialogue about parental vaccine concerns.