Background: Poor demand for vaccines has long been recognized as a threat to the realization of public and global health objectives. Consequently, over time a range of interventions have been researched, proposed, and implemented in an attempt to improve the acceptability of vaccines and overcome vaccine resistance. However, much of the contemporary research concentrates disproportionately on individual-level determinants as viable targets for interventions. This disparate focus on individual-level factors has seemingly been at the expense of research into fundamental contextual influences. As a result, the primary aim of this thesis is to explore and develop a greater understanding of the contextual determinants of vaccine acceptability and their evolution over time and across different global contexts. Furthermore, emerging themes will be analyzed in an effort to explore how different contextual determinants work together or separately to influence vaccine acceptability. Methodology: The methodological approach adopted for this thesis concentrated on enabling and conducting an in-depth literature review of the contextual determinants of vaccine acceptability. To begin, a concept analysis was conducted to inform the design, focus, and implementation of a literature review. Subsequently, an in-depth literature review of research derived from the Global Health database was conducted using relevant papers published between 1910 and 2022. Data related to publication and content characteristics were extracted to support the analysis process and discussion. Ultimately themes related to the seven contextual determinants categories were identified, extracted, and analyzed. Results: Through the final analysis, 32, often interrelated themes were identified across the seven contextual determinant categories. The determinant category of Politics & Policy was found to be relevant in 70.5% (n=98) of articles included in this literature review. Religious, Social & Cultural determinants were relevant in 53.24% (n=74) of articles, followed by Communication & Media Environment at 43.16% (n=60), Influential Leaders at 41.37% (n=58), History & Historical Factors at 38.13% (n=53), Pharmaceutical Influences at 24.46% (n=34), and Geographic Influences at 18.7% (n=26). Conclusion: The acceptability of vaccines is undoubtedly influenced by the broader factors that shape the contexts in which vaccines are delivered. Additionally, these contextual determinants are likely to interact with, or influence the many commonly referenced putative individual-level determinants of vaccine acceptability. As a result, the complex nature of any relevant contextual determinants should be considered in the design of efforts aimed at promoting or improving demand for vaccines. / Thesis / Master of Science (MSc) / The contextual determinants of vaccine acceptability have been seemingly under- researched relative to other individual-level factors. As a result, this thesis aims to explore and develop a greater understanding of the contextual determinants of vaccine acceptability and their evolution over time and across different global contexts. To achieve this objective, an in-depth literature review of 139 identified articles was conducted in an effort to explore and identify themes related to the contextual determinant of vaccine acceptability. Ultimately, through this review 32 themes across the seven contextual determinant categories were identified and discussed. These findings helped elucidate the complex and fundamental role that contextual determinants have in shaping demand for vaccines.

Widespread use of childhood vaccination has significantly reduced the burden of childhood disease, however a subset of parents are choosing to delay or refuse available vaccines. This study analyzed data collected from a large surveillance study to examine the parents’ attitudes about vaccines and the prevalence of vaccine hesitancy (vaccine delay and refusal) in an urban clinic population. The parents of 961 children attending the Boston Medical Center Pediatrics department participated in the study. Parental responses to four vaccine questions were used to assess vaccine attitudes. Log-Binomial Regression models were used to evaluate the relationship between comorbidity status and birth order with vaccine delay or refusal. In this study population, parents reported generally positive attitudes toward vaccination. The majority (87%) believed that vaccines were necessary to protect their child. Approximately 16% of parents reported that had delayed or refused a vaccine and 24% of parents indicated that they did not believe or were unsure if other parents vaccinating their children. When asked the reason for their choice, parents who only delayed frequently cited logistic concerns like a missed appointment, whereas parents who refused more often cited personal beliefs, such as concerns that their child could become ill from vaccination. Finally, parents of children with a comorbidity were more likely to refuse a vaccine than parents of children without comorbidity (Adjusted RR=1.8, 95% CI: 1.1, 2.9). While parents were generally positive toward vaccines, for the small portion of parents refusing vaccines, further work could help to better explain their motivations.

Indiana University-Purdue University Indianapolis (IUPUI) / During the last two years, women of reproductive age (WRA) have experienced uncertainty about the COVID-19 vaccine, particularly as it relates to reproductive health (e.g., fertility) due to the COVID-19 infodemic. Because WRA are a pivotal population in pandemic control, it is important to understand how WRA manage vaccine-related uncertainty. Uncertainty management theory (UMT) considers the complexities of uncertainty, acknowledging that individual appraisals of, and responses to, uncertainty may vary from person to person and evolve over time. This study examined factors contributing to WRA’s hesitancy to receive the COVID-19 vaccine, including uncertainty about potential side effects, concern about safety and efficacy, and conflicting information. WRA most frequently felt neutral towards their uncertainty; however, negative emotional responses to uncertainty played an influential role in many WRA’s responses to uncertainty (e.g., avoiding information, seeking information, receiving the COVID-19 vaccine). The findings of this study provided insight on how WRA have experienced uncertainty about the COVID-19 vaccine, including their emotional responses to and subsequent appraisals of their uncertainty which ultimately influenced their responses.

The purpose of this project is to develop a clinical practice guideline with recommendations for vaccination and vaccine hesitancy in the pediatric setting. Routine vaccinations are given to children at recommended ages to decrease the incidence of, and prevent infectious disease. These vaccinations prevent diseases such as rotavirus, diphtheria, pertussis, tetanus, hepatitis B, haemophilus influenza type B, pneumococcal disease, polio, influenza, measles, mumps, rubella, varicella and hepatitis A. There are currently no guidelines that combine evidence-based interventions to increase vaccination rates, the recommended vaccine schedule, specific information on each vaccination, its side effects, and ingredients of each vaccination. By developing this guideline, it is hoped that pediatric providers will be able to effectively approach the caregivers of vaccine-aged children with evidence based information about vaccination, and be able to address specific concerns regarding vaccines. The available literature was formally evaluated using GRADEpro software. These results were put into the BRIDGE-Wiz (Building Recommendations in a Developer ’s Guideline Editor) software to create clear, concise, key action statements for the guideline. There were five recommendations that were created based on the literature review which include assessing parental concerns regarding vaccination at each visit, educating parents on vaccination, each vaccine, at each visit and when concerns arise, recommending vaccinations during each visit and when the opportunity arises, recommending pre-scheduling vaccination appointments, and implementing a reminder/recall system when vaccinations are due or past due. There were also informational tables created for provider reference that include important information regarding vaccines. The first table includes each vaccination, the disease it prevents, and the risk of the disease vs the risk of the vaccination. The second table includes the vaccine ingredients that commonly cause concern, and information to address those concerns. The guideline can be used in pediatric primary care to guide interventions to increase the uptake of vaccinations, and as a tool for providers to use while educating parents on specific vaccinations. The guideline was formally evaluated using the AGREE II tool by three experts in the field of pediatric primary care. All three of the reviewers stated that they would recommend the guideline for use in the pediatric setting.

The overarching objective of this thesis was to investigate the phenomenon of vaccine hesitancy in Canada and examine relationships among vaccine beliefs, socio-demographic characteristics, and seasonal influenza immunization. Quantitative findings were derived from a national health risk perception survey administered to adults across Canada (N = 1,125). Respondents were asked to provide their level of agreement (1 = do not agree at all to 5 = agree completely) with 2 vaccine-related behaviour statements and 21 vaccine-related beliefs statements. A principal components analysis was performed to reduce the number of belief statements into meaningful components. Two components were retained and reflected negative beliefs about ‘vaccine safety’ and positive beliefs about ‘vaccine regulation and benefits’. Descriptive results presented in the first study indicated a heightened uncertainty about the long-term side effects of vaccination, particularly with respect to the purported link between the Measles-Mumps-Rubella vaccine and the development of autism, among survey respondents. Multivariate analyses identified differences in the endorsement of numerous vaccine beliefs according to age and educational attainment. Findings revealed that older respondents and respondents without a university education demonstrated more negative attitudes towards vaccination, whereas younger respondents and respondents with a university education demonstrated more positive vaccine attitudes, respectively. Finally, both components of vaccine beliefs were significant predictors of vaccine-related behaviours, including discussing information about vaccines with others and reported receipt of the seasonal influenza vaccine. The second study investigated interrelationships among components of vaccine beliefs, socio-demographic characteristics, and reported receipt of the seasonal influenza vaccine. A mediation analysis revealed that higher levels of agreement with the statement ‘I usually get the seasonal flu vaccine’ among older adults was associated with lower levels of agreement with negative beliefs about vaccine safety in conjunction with higher levels of agreement with positive beliefs about the regulation and benefits of vaccines, whereas the opposite was true for younger adults. Also, a significant moderation analysis revealed that among respondents with greater concern about vaccine safety, those with higher educational attainment reported lower levels of agreement with the statement ‘I usually get the seasonal flu vaccine’ compared to those with lower educational attainment. Recognizing the limitations of quantitative findings, a qualitative investigation was undertaken to provide more in-depth insight on the factors driving influenza immunization among healthy adults. A thematic analysis was performed on transcripts from 6 semi-structured focus group discussions with a total of 18 participants residing in Ottawa, Ontario. Findings identified 7 themes and 8 sub-themes related to contextual, vaccine specific, and individual determinants of vaccine hesitancy. Participants predominantly discussed themes related to individual determinants of vaccine hesitancy (perceived severity, susceptibility, and likelihood of contracting the influenza virus; personal interests; interactions with healthcare professionals). The perceived novelty, severity and effectiveness of the influenza vaccine, as well as a lack of information and discontent with communication by government health authorities and the media were also discussed. Overall, findings identified salient themes informing vaccine decision-making and behaviours among a sample of educated adults, which can inform subsequent studies investigating influenza immunization in a more representative sample of Canadian adults.

Since the first vaccine was invented in the late eighteenth century, vaccines revolutionized biomedical approaches to infectious disease prevention and saved hundreds of millions of lives from smallpox, influenza, measles, whooping cough, and Covid-19. Despite the undeniable success of this medical technology, vaccines have always given some people pause, and others have steadfastly rejected vaccinations for themselves and their children. Although historians and social scientists have explained many causes of vaccine hesitancy in the United States, this dissertation is the first analysis of vaccine hesitancy that treats it as a part of United States religious history. Covering three hundred years of vaccine history, this dissertation charts and analyzes the religious concepts and bodily practices that informed increasing vaccine skepticism over four different historical periods, culminating in the Covid-19 era. It explains how vaccine skeptics crafted their arguments, worldviews, and bodily practices and why their skepticism was often subtly religious. Vaccine skeptics routinely placed religious ideas––purity vs. pollution, sacralized motherhood and childhood, divine sovereignty, and moral individualism––at the center of their arguments against vaccines. To protect bodily sovereignty and purity, they enacted rituals to stave off corruption. These rituals included self-education, holistic healing, intensive mothering, and detoxing bodies and environments. In different eras, skeptics created moral communities that coalesced behind shared values about bodies, health, and wellness. They negotiated the limits of bodily and medical authority, the responsibility of the individual to the collective, and the connection between the worldly physical body and the transcendent soul. Skeptics perceived the standardizations required of biomedicine and public health as immoral, so they agitated against state-mandated vaccinations. Their moral communities were prevalent on both the Left and the Right of the religious and political spectrums in the United States. From the debates over smallpox inoculations in colonial Boston to the furor over Covid-19, they have found common ground where few other movements have.

BACKGROUND: Recently there has been a shift in the global health arena towards maternal immunization as the missing link to protect mother, fetus, and infant. However, as research is being conducted across the maternal immunization portfolio to address underlying immunological mechanisms, effectiveness, stability, and safety, there is minimal data regarding acceptance from the perspective of women and providers, specifically in low-resource settings. Serving as a factor that informs a global and national recommendation for vaccine use, closing this knowledge gap will be necessary to reach policy decisions, develop strategies to introduce maternal vaccines into National Immunization Programs, and secure uptake of such policies on the part of intended beneficiaries. METHODS: Qualitative data was collected across three health facilities (urban, peri-urban, rural) via focus group discussions (women), key informant interviews (family/community members), and clinical vignettes (women). Thematic analysis was guided by the World Health Organization’s Model of Determinants of Vaccine Hesitancy using the seven stages of the Framework Method. RESULTS: Results demonstrated that while women showed confidence in the safety and efficacy of vaccines, hesitancy towards maternal vaccination was fostered by misinformation, religious beliefs, use of traditional medicine, social norms, family involvement, and concerns about risk benefit profiles. In contrast, providers expressed service delivery barriers such as long wait times, husband involvement in decision-making, and religion as main reasons why women were hesitant to be vaccinated during pregnancy. Providers believed that these barriers could easily be overcome with proper outreach, education, and modifications to service delivery. Additionally, providers displayed confidence in their own understanding of the vaccine ecosystem and the level of knowledge women possessed about vaccines. CONCLUSION: To ensure the full potential of maternal vaccines, policies, national strategies, and implementation approaches will need to consider knowledge, attitudes, and beliefs expressed by women and providers, as well as the cultural dynamics of the setting in which vaccines are being administered. Furthermore, research is required to understand the relative strength of explanatory factors in deciding to be vaccinated during pregnancy, as well as exploration of how these factors change over time and contribute to policy and program implementation approaches. / 2022-09-30T00:00:00Z

Bakgrund: Vacciner har under många år varit en av de största bidragande faktorerna till en god folkhälsa. När många invånare vaccinerar sig skyddas fler mot smittsamma virussjukdomar i samhället. En tveksamhet till vacciner finns trots det hos många människor. Syfte: Syftet var att undersöka orsaker till vaccinationstveksamhet hos vuxna. Metod: En allmän litteraturstudie genomfördes för att besvara syftet. Tre databaser användes för informationssökning. Innehållet i artiklarna granskades med stöd av kategorisering av åsikter i en tabell. Resultat: Resultatet för litteraturstudien består av fyra kvantitativa artiklar, fem kvalitativa samt en med mixad metod. Fyra kategorier påvisades: brist på kunskap, oro, rädsla och brist på tillit, brist på stöd och attityder och kulturella aspekter. I resultatet framkom ett flertal anledningar till att individer erhöll en tveksamhet till vaccin däribland bristande kunskap och rädsla. Slutsats: Mer forskning krävs för att identifiera åtgärder som sjuksköterskan kan använda sig av i mötet med patienter som är tveksamma till vaccin. / Background: For many years, vaccines have been one of the major contributing factors to good public health. The fact that many people vaccinate provides protection against several viral diseases in society. Nevertheless, there are many people that have doubts about vaccines. Objective: The aim of the literature study was to investigate the causes of vaccination hesitancy with adults. Methods: A general literature study was conducted to answer the purpose. Three databases where used for information retrieval. The content of the articles was examined with the aid off categorization of opinions in a table. Results: The result of the literature study consists of four quantitative articles, five qualitative articles and one with a mixed method. The content of the articles was reviewed, and four categories were identified: lack of knowledge, concerns, fears and lack of trust, lack of support and attitudes and cultural aspects. In the results, there were a number of reasons why individuals hold a doubt towards vaccine, including lack of knowledge and fear. Conclusion: More research is needed to identify actions that the nurse can use when meeting patients with vaccine hesitancy.

Vaccinations are among the greatest accomplishments of public health. However, many parents are choosing not to vaccinate. The purpose of this study was to explore the association between social media influence and parents' decisions to vaccinate their children. The health belief model indicates that individuals' likelihood of engaging in a health-related behavior is determined by their perceptions of susceptibility, severity, benefits, and barriers. The research questions addressed whether there is an association between parents' perception of their children's disease susceptibility and their decisions about vaccination, and whether there is an association between exposure to messaging from social media and parents' decision to vaccinate. A quantitative, cross-sectional research design was used. The primary dependent variable was vaccination choices, and the primary independent variable was exposure to information about vaccination through social media. Data were gathered through a questionnaire administered to 269 White parents residing in Illinois with their own children between the ages of 0 and 18 years living with them. Binomial logistic regression showed that there was not a statistically significant relationship between parents' perception of disease susceptibility and vaccination choice or between parents' vaccination choice and exposure to online antivaccine advertisements. These study findings help in defining an overall picture of vaccine hesitancy in the United States. By focusing on the predictors of this behavior, it may be possible to implement interventions to combat the antivaccine movement with the goal of increasing vaccine compliance among parents.

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