Assessing Vaccine Hesitancy among Healthcare Workers: A Cross-Sectional Study at an Italian Paediatric Hospital and the Development of a Healthcare Worker's Vaccination Compliance Index

A systematic review of measures of healthcare workers' vaccine confidence

Healthcare workers (HCW) perceptions toward vaccines influence patient and community vaccine decision making. In an era of rising vaccine hesitancy, understanding HCW vaccine confidence is critical. This systematic review aims to review instruments that have been validated to measure HCW vaccine confidence. We conducted a search in five databases in June 2023. Data was descriptively synthesized. Twelve articles describing 10 different tools were included. Most tools included dimensions or items on vaccine knowledge (n = 9), safety (n = 8), vaccine usefulness (n = 8), recommendation behavior (n = 8), and self-vaccination practice (n = 7). All, except one study, were conducted in high-income countries. There was variability in the quality of the validation process. There is limited existing literature on development and validation of tools for HCW vaccine confidence. Based on the tools currently available, the Pro-VC-Be tool is the most well validated. Further research needs to include low- and middle-income contexts.

Development and validation of an Arabic tool for assessment of post-vaccination confidence in COVID-19 vaccines (ARAB-VAX-CONF)

BACKGROUND

Vaccine confidence is described as a belief that vaccines are effective, safe, and part of a trustworthy health system. The objective of this study was to develop and validate an Arabic tool to evaluate confidence in the received coronavirus disease 2019 (COVID-19) vaccines (ARAB-VAX-CONF).

METHODS

The research team developed the ARAB-VAX-CONF based on three areas specified by the Centers for Disease Control and Prevention (CDC): confidence in vaccine effectiveness, confidence in vaccine safety, and confidence in the healthcare system. The analysis includes data from 406 eligible vaccinated persons (≥ 18 years). Cronbach's alpha was used to measure internal consistency, while convergent, discriminant, exploratory, and confirmatory factor analyses were used to verify construct validity.

RESULTS

A total of 406 adults were recruited, with a mean age of 33.0 ± 12.2 years. A total of 63.1% were males, 56.7% were married, 21.9% had chronic conditions, 93.3% were nonsmokers, and 39.6% were obligated to obtain vaccines. The three domains of the scale met the criterion of internal consistency (Cronbach's alpha > 0.7). Convergent validity was identified by the significant inter-item and item-mean score of the domain correlation (P < 0.001). Discriminant validity was reported as the inter-factor correlation matrix (< 0.7). The Kaiser-Meyer-Olkin sampling adequacy measure was 0.80, and Bartlett's sphericity test was significant (P < 0.001). Exploratory factor analysis indicated that the scale could be summarized into three factors. Confirmatory factor analysis confirmed the adequate psychometric properties and fit with observed data (root-mean-square error of approximation = 0.08, comparative fit index = 0.945, Tucker-Lewis index = 0.924, standardized root-mean-square residual = 0.086, normed fit index = 0.918, and goodness-of-fit index = 0.909).

CONCLUSIONS

The ARAB-VAX-CONF developed in this study is valid and reliable for assessing confidence in vaccine effectiveness, safety, and confidence in the healthcare system. The ARAB-VAX-CONF can support decision-makers in addressing the gap in vaccine confidence among various populations.

Anti-Herpes Zoster Vaccination of Fragile Patients in Hospital Setting: A Nudge Intervention in Italy

BACKGROUND

A nudge intervention against Herpes Zoster, created and implemented in Italy, is presented in order to administer the Shingrix vaccine on a sample of frail patients, as required by the National Prevention Plan. Individual and contextual factors associated with vaccine adherence were investigated.

METHOD

300 frail adult subjects underwent a full vaccine cycle with recombinant-Shingrix vaccine (RZV vaccine). Hospital Presidia of the Salerno University Hospital Authority, a Hospital Presidium of the Salerno Local Health Authority, and the Public Health Laboratory of the University of Salerno (Campania) participated in the intervention. An ad hoc questionnaire was administered with the following scales: EQ-5D, PSS-10, MSPSS, and representations of HZ and its consequences.

RESULTS

Some variables, such as peer support, doctor-patient relationship, level of education, and perception of health, are important in vaccine adherence and information processing. The following factors emerged from the factor analysis: Trust in collective knowledge and collective responsibility (F1); beliefs about virus risk and vaccine function (F2); information about virus and symptomatology (F3); and vaccine distrust (F4). Factor 4 correlates negatively with social support indices (R = -0.363; p < 0.001). There is a significant relationship between factor 3 and satisfaction with national information campaigns (F = 3.376; gdl = 5; p-value = 0.006).

CONCLUSIONS

Future vaccination campaigns should be built with the aim of personalizing information and developing contextualized strategies, starting from understanding the stakeholders involved, cultural contexts, and organizational settings.

Behind Coronavirus Disease 2019 Vaccine Hesitancy of Filipino Nurses: A Thematic Approach

The study aimed to explore the reasons for nurses' coronavirus disease 2019 vaccine hesitancy in the Philippines. This study used descriptive, phenomenological qualitative research. The data were collected from 13 Filipino nurses using an unstructured interview questionnaire from June 2021 to October 2021. The six phases method of Braun and Clarke was used to analyze the data. The rigor or trustworthiness of the study was ensured by observing dependability, transferability, credibility, confirmability, and reflexivity. The study shows six significant themes; "being altruistic," "being circumspect," "vaccine brand distrust," "vaccine trauma," "perceived physical endurance," and "effects of religious belief and practice." In general, the reasons behind hesitancy on coronavirus disease 2019 vaccine were associated with their previous vaccine experiences, faith, vaccine brand distrust, altruistic behavior toward vaccines, and maintaining physical health among Filipino nurses. These are multifaceted yet exist in close relation. Therefore, these necessitate further understanding of its complexities, as they may contribute to society's outlook toward coronavirus disease 2019 vaccination.

Attitudes toward influenza vaccination in healthcare workers in Italy: A systematic review and meta-analysis

Healthcare workers (HCWs) are among the at-risk groups for whom influenza vaccination is strongly recommended. To assess the proportion of Italian HCWs with positive attitudes toward influenza vaccination, we conducted a systematic review of relevant literature and a meta-analysis. Our focus was on the influenza seasons from 2017/18 to 2021/22. The prevalence of favorable attitudes toward vaccination varied, ranging from 12% during the 2017/18 influenza season to 59% in the 2020/21 season. The significant increase in the 2020/21 season can be attributed to adaptations necessitated by the COVID-19 pandemic. During the 2021/22 influenza season, there was a decline in vaccination coverage (37%), likely due to the absence of a robust preventive culture. Various strategies have been employed to enhance HCWs' attitudes to achieve higher vaccination rates, but none of them have demonstrated satisfactory results. Policymakers should consider implementing a policy of mandatory vaccination to ensure elevated vaccination coverage among HCWs.

Vaccination willingness, vaccine hesitancy, and estimated coverage of SARS-CoV-2 vaccine among healthcare workers in Tanzania: A call for action

BACKGROUND

The global COVID-19 pandemic presented an immense obstacle to public health, with vaccination emerging as a crucial measure to curb transmission. This study aimed to evaluate the willingness, hesitancy, and coverage of SARS-CoV-2 vaccines among healthcare workers (HCWs) in Tanzania and reveal their concerns about SARS-CoV-2 vaccines and the reasons that might prevent them from getting vaccinated.

METHODS

We conducted a cross-sectional study using an anonymous online survey from October to November 2022. The multivariate logistic regression model explored the factors associated with SARS-CoV-2 vaccine willingness, hesitancy, and coverage.

RESULTS

The study included 560 HCWs, with the largest group being doctors (47.9%), followed by nurses (26.9%) and other HCWs (25.2%). A total of 70.5% of HCWs reported being vaccinated against SARS-CoV-2. The primary driver for SARS-CoV-2 vaccination was collective responsibility. A total of 81.4% of HCWs reported being willing to accept SARS-CoV-2 vaccines, while 62.5% of HCWs reported vaccine hesitancy. HCWs with higher educational qualifications were likelier to take the vaccine, while the respondents aged 18-30 years had the highest SARS-CoV-2 vaccination refusal (71.9%). We also investigated the role of HCWs as a source of information to promote COVID-19 vaccine uptake. 79.4% of HCWs provided information and advice on SARS-CoV-2 vaccines.

CONCLUSION

To increase vaccine acceptance among HCWs and the general population, targeted messaging is needed to deliver transparent information on vaccine safety, efficacy, and development.

Vaccine Hesitancy among Healthcare Workers in Europe: A Systematic Review

This study analyzes vaccine hesitancy (VH) among healthcare workers (HCWs) in 15 European countries. We have undertaken a systematic review by synthesizing data from 46 articles (between 2015 and 2022) encompassing 55,612 subjects. Despite the heterogeneity of the methods in the various studies, we found that physicians had consistently higher vaccination rates than nurses across different countries and different vaccines. Physicians' average vaccination rate was 79% across a selection of vaccines, while that of nurses was 62%. Concerns regarding vaccine safety, information gaps, and the responsibility of healthcare authorities in managing VH are highlighted by qualitative insights. This research contributes to our comprehension of the ways in which VH among HCWs is impacted by healthcare roles, vaccine types, and regional disparities. The insights gleaned from this analysis can serve as a guide for targeted interventions aimed at increasing vaccine acceptance and coverage in Europe, ultimately strengthening public health.

Influenza vaccine coverage among healthcare workers: A cluster analysis from a cross-sectional survey

OBJECTIVES

Influenza vaccination is recommended for healthcare workers (HCWs). However, in a 1500-bed tertiary care university hospital in France, influenza vaccine coverage among HCWs was 23% in 2017.

PATIENTS AND METHODS

We performed a cross-sectional study between 05/09/2018 and 25/09/2018 among HCWs, randomly selected independent of their vaccination status, to estimate influenza vaccination coverage rate during the 2017-2018 season, and explore factors influencing vaccination, using a questionnaire. Multivariable regression analysis to assess factors associated with vaccine uptake and hierarchical clustering on principal components to identify HCW profiles regarding factors influencing vaccine uptake, were performed after multiple imputation.

RESULTS

977 HCWs were included (68% participation rate), primarily females (84%), nurses (38%) of 18-39 years old. Influenza vaccination coverage rate reached 33[30-36]%. Frequent vaccination (aOR 39.27[21.52-74.51]) and personal/family medical history of influenza (aOR 3.33[1.16-10.02]) were independently associated with vaccination. In HCWs' patterns of influenza vaccination status, three clusters were identified: 1) (n = 438) mostly vaccinated (70%); 2) (n = 507) most unvaccinated (97%); and 3) (n = 32) unvaccinated HCWs lacking knowledge on influenza and influenza vaccine. Among the 148 (15%) HCWs reluctant to receive the vaccine the following year, 23 (16%) received it for the 2017-2018 season, while 125 (84%) did not, mostly stating they had doubts about the vaccine (82%).

CONCLUSION

This work identifies determinants of vaccine uptake and highlights HCWs profiles associated with factors influencing vaccination and a subgroup of HCWs flexible about having the vaccine during the upcoming seasonal campaign. This result opens up perspectives toward improved vaccination coverage among HCWs.

Does Vaccine Confidence Mediate the Relationship between Vaccine Literacy and Influenza Vaccination? Exploring Determinants of Vaccination among Staff Members of Nursing Homes in Tuscany, Italy, during the COVID-19 Pandemic

BACKGROUND

Low coverage of influenza vaccination in nursing home (NH) staff may be attributed to factors such as vaccine confidence (VC) and vaccine literacy (VL). Our study aimed to evaluate the role of VL and VC in predicting the intention to get the influenza vaccine in a sample of employees of NHs in Tuscany, Italy.

METHODS

Data from staff members in Tuscany were collected using an online questionnaire that examined influenza vaccination history, intentions, demographic information, health status, and VL. Statistical analyses explored the relationships between VC, VL, and vaccination intentions.

RESULTS

The study included 1794 respondents, (86.3%) and assistants/aides (58.1%), with a median age of 46 years. The intention to get vaccinated was significantly higher among those with health risk conditions, and there was a positive association between VC and VL, specifically its interactive/critical component. The mediation analysis showed that VC completely mediated the relationship between VL and the intention to get vaccinated, with significant effects observed in different subgroups.

CONCLUSIONS

VC is a key factor that mediates the effect of VL on vaccine intention. These results suggest that interventions aimed at improving VL alone may not be sufficient to increase vaccine uptake unless VC is also addressed.

Influenza Vaccination Uptake and Prognostic Factors among Health Professionals in Italy: Results from the Nationwide Surveillance PASSI 2015-2018

(1) Influenza causes a significant health and socio-economic burden every year, and health personnel (HP) are at higher risk of exposure to respiratory pathogens than the general population. (2) The study's purpose was to describe and compare influenza vaccine uptake and its prognostic factors among Medical Doctors (MDs) and Non-Medical Health Personnel (NMHP) vs. Non-HP (NHP). We analyzed 2014-2018 data (n = 105,608) from the Italian Behavioral Risk Factor Surveillance System PASSI that, since 2008, has been collecting health-related information continuously in sampled adults. (3) MDs and NMHP represented, respectively, 1.1% and 4.6% of the sample. Among HP, 22.8% (CI 19.8-26.1%) of MDs and 8.5% (CI 7.5-9.5%) of NMHP reported to have been vaccinated vs. 6.3% (CI 6.1-6.5%) in NHP. This difference is confirmed in the three categories (MDs, NMHP, NHP), even more across age groups: in 18-34 yy, respectively, 9.9%, 4.4%, 3.4% vs. 28.4%, 13.9%, 10.6% in 50-64 yy. PASSI surveillance shows an increasing influenza vaccination uptake over time, especially among MDs (22.2% in 2014 vs. 30.5% in 2018). (4) Despite such an increase, especially among younger HP, influenza vaccination uptake is low. Even more under pandemic scenarios, these figures represent key information to address effective strategies for disease prevention and health promotion.

Optimizing Your Pediatric Office for Vaccine Confidence

Parents trust their pediatric clinicians for up-to-date information about vaccines. To reduce vaccine hesitancy, clinics must promote confidence by building trust, communicating clearly, using patient safety and infection control principles to reduce errors, and reducing missed opportunities by having a vaccination infrastructure that makes every visit a vaccine visit. Education and communication must be consistent among all staff and culturally competent to optimize vaccine confidence. Parents have a role in seeking reliable resources, raising concerns, and seeking trusted, evidence-based experts for vaccination conversations. Safe, effective vaccines are vital; however, vaccination, a complex operational process, prevents disease and saves lives.

Perceptions of COVID-19 Vaccines: Protective Shields or Threatening Risks? A Descriptive Exploratory Study among the Italian Population

Although several quantitative studies have explored vaccine hesitancy, qualitative research on the factors underlying attitudes toward vaccination is still lacking. To fill this gap, this study aimed to investigate the general perceptions of COVID-19 vaccines among the Italian population with a qualitative approach. The sample included 700 Italian participants who completed an online survey. Open questions underwent a descriptive analysis for unveiling meaning categories, while differences in the prevalence of categories were calculated using chi-square or Fisher's exact tests. Vaccination was associated with the following seven main themes: 'safety', 'healthcare', 'vaccine delivery', 'progress', 'ambivalence', 'mistrust', and 'ethics'. Vaccinated individuals more frequently reported words related to the safety theme (χ2 = 46.7, p < 0.001), while unvaccinated individuals more frequently reported words related to mistrust (χ2 = 123, p < 0.001) and ambivalence (χ2 = 48.3, p < 0.001) themes. Working in the healthcare sector and being younger than 40 years affected the general perceptions of vaccination in terms of pro-vaccine attitudes. Unvaccinated individuals were more affected by the negative experiences of their acquaintances and manifested more distrust of scientific researchers, doctors, and pharmaceutical companies than vaccinated individuals. These findings suggest promoting collaborative efforts of governments, health policymakers, and media sources, including social media companies, in order to deal with cognitions and emotions supporting vaccine hesitancy.

Factors influencing healthcare professionals' confidence in vaccination in Europe: a literature review

Health-care professionals (HCPs) have a fundamental role in vaccination, their own beliefs and attitudes affecting both their uptake and recommendation of vaccines. This literature review (n = 89) summarises evidence on HCPs’ perceptions of the risks and benefits of vaccination, trust, and perceptions of mandatory vaccination in Europe. HCPs across studies believed that vaccination is important to protect themselves and their patients. However, beliefs that some diseases such as influenza are less risky were reported by some HCPs as a reason for not getting vaccinated. Concerns about both short- and long-term side effects were identified among HCPs in most studies, such as those affecting the immune or neurological system. Mistrust toward health authorities and pharmaceutical industry was reported in some studies. The question of mandatory vaccination revealed mixed opinions, with some favoring self-determination and others viewing vaccination as a duty. This review highlights key factors influencing HCPs’ confidence in vaccination in Europe.

A systematic literature review to clarify the concept of vaccine hesitancy

Vaccine hesitancy (VH) is considered a top-10 global health threat. The concept of VH has been described and applied inconsistently. This systematic review aims to clarify VH by analysing how it is operationalized. We searched PubMed, Embase and PsycINFO databases on 14 January 2022. We selected 422 studies containing operationalizations of VH for inclusion. One limitation is that studies of lower quality were not excluded. Our qualitative analysis reveals that VH is conceptualized as involving (1) cognitions or affect, (2) behaviour and (3) decision making. A wide variety of methods have been used to measure VH. Our findings indicate the varied and confusing use of the term VH, leading to an impracticable concept. We propose that VH should be defined as a state of indecisiveness regarding a vaccination decision.

Multifactorial influences underpinning a decision on COVID-19 vaccination among healthcare workers: a qualitative analysis

COVID-19 vaccination in healthcare workers (HCW) is essential for improved patient safety and resilience of health systems. Despite growing body of literature on the perceptions of COVID vaccines in HCWs, existing studies tend to focus on reasons for 'refusing' the vaccines, using surveys almost exclusively. To gain a more nuanced understanding, we explored multifactorial influences underpinning a decision on vaccination and suggestions for decision support to improve vaccine uptake among HCWs in the early phase of vaccination rollout. Semi-structured interviews were undertaken with thirty-three HCWs in Singapore. Transcribed data was thematically analyzed. Decisions to accept vaccines were underpinned by a desire to protect patients primarily driven by a sense of professional integrity, collective responsibility to protect others, confidence in health authorities and a desire to return to a pre-pandemic way of life. However, there were prevailing concerns with respect to the vaccines, including long-term benefits, safety and efficacy, that hampered a decision. Inadequate information and social media representation of vaccination appeared to add to negative beliefs, impeding a decision to accept while low perceived susceptibility played a moderate role in the decision to delay or decline vaccination. Participants made valuable suggestions to bolster vaccination. Our findings support an approach to improving vaccine uptake in HCWs that features routine tracking and transparent updates on vaccination status, use of institutional platforms for sharing of experience, assuring contingency management plans and tailored communications to emphasize the duty of care and positive outlook associated with vaccination.

Mapping the Prevalence of COVID-19 Vaccine Acceptance at the Global and Regional Level: A Systematic Review and Meta-Analysis

Despite the availability of effective and safe vaccines, the acceptance of COVID-19 vaccination is suboptimal. In this meta-analysis we quantified the prevalence estimates of COVID-19 vaccine acceptance with a specific focus on worldwide geographical differences. We searched PubMed, Scopus, Web of Science and PsycInfo up to April 2021 (PROSPERO ID: CRD42021235328). Generalized random-effects linear models with a logit link were used to calculate the pooled estimated rate of vaccine acceptance at both the global and regional level. A meta-regression analysis was performed to assess the association between COVID-19 vaccine acceptance and various characteristics of the studies. Overall, 71 articles yielding 128 prevalence estimates were included. The pooled prevalence of COVID-19 vaccination acceptance rate was 66% (95% CI: 61-71%). This varied by geographic area, ranging from 36% (95% CI: 18-60%) in Africa to 83% (95% CI: 82-84%) in Oceania, and there was high variability between countries (15.4% Cameroon-100% Bhutan). Meta-regression analysis showed that studies that investigated COVID-19 vaccination intentions using multiple choice/scoring gave a vaccine acceptance prevalence lower than studies with only two possible answers (yes/no) (ß: -1.02 95% CI: -1.41 to -0.63). Despite some variation in the estimates, the results showed that one in three people may refuse/delay COVID-19 vaccination.

Vaccine Literacy, COVID-19 Vaccine-Related Concerns, and Intention to Recommend COVID-19 Vaccines of Healthcare Workers in a Pediatric and Maternity Hospital: A Cross-Sectional Study

Vaccine literacy of healthcare workers (HCWs) may affect the COVID-19 vaccine uptake of the general population. This study aimed to clarify the vaccine literacy level of HCWs in Japan and its impacts on their concerns about vaccines and intention to recommend that others receive vaccines. This cross-sectional survey was conducted in July 2021 based on the recruitment of HCWs in a pediatric and maternity hospital and research center in Tokyo, Japan. All HCWs in this center had the chance to receive the COVID-19 vaccine before the survey, and their vaccine coverage was relatively high, at 95%. A total of 1519 workers answered the questionnaire. The results showed that HCWs with lower functional vaccine literacy had 1.5 times as many concerns about the efficacy of vaccines and 1.6 times as many concerns about the future side effects compared with those with higher literacy. Further, HCWs with higher vaccine literacy were more likely to recommend that older people, people with comorbidities, and pregnant women receive vaccines. Our findings suggest that high vaccine literacy alleviates concerns about COVID-19 vaccines and raised the intention to recommend vaccines to others. To achieve high vaccine coverage, countermeasures such as personalized education are essential.

Pilot Study of Evaluating Attitudes toward Childhood Immunization among Healthcare Workers in Japan

Providing appropriate immunization information during the perinatal period is important for improving immunization rates among infants and children; however, the distribution of immunization information by healthcare workers (HCWs) is not standardized in Japan. We investigated HCWs’ attitudes toward childhood immunization and factors related to vaccine hesitancy. We conducted a cross-sectional descriptive survey of HCWs involved in childhood immunization in Niigata City, Japan, from November 2017 to January 2018. We assessed contextual, individual and group, and vaccine/vaccination-specific influences. Of 290 HCWs, 139 (47.9%) returned completed questionnaires. Most HCWs (87/139, 64.9%) reported providing immunization information verbally to parents; 51/87 (58.6%) spent fewer than five minutes doing so. Pediatricians provided vaccines based on the parents’ best interest, whereas public health nurses and midwives emphasized government policy. Nurses had greater hesitancy related to personal perceptions and social/peer factors than pediatricians (p < 0.001). Nurses were significantly more likely than pediatricians to suggest that children receive more shots than necessary (p < 0.01). Nurses tended to have more negative attitudes toward vaccination and little awareness of immunization promotion compared to pediatricians. Thus, all HCWs involved in childhood immunization should receive sufficient information to provide timely and appropriate immunization to infants and children.

Exploring the Motivational Roots of Getting Vaccinated against COVID-19 in a Population of Vaccinated Pediatric Healthcare Professionals: Evidence from an Italian Cross-Sectional Study

Health care professionals (HCPs) working in pediatric and perinatal settings have a strong influence on parental vaccine decision making. Furthermore, HCPs' motivations behind vaccine acceptance are associated with their likelihood of recommending vaccines to their patients. Understanding these motivations in the context of the COVID-19 vaccination campaign may aid in the development of interventions that improve pediatric practitioners' vaccine confidence and prescription. We aimed at studying the motivations affecting COVID-19 vaccination behavior among a sample of vaccinated Italian HCPs working in pediatric settings. A sample (n = 162) of HCPs completed an online self-reported survey exploring motivations behind getting vaccinated against COVID-19. Emotions of HCPs at the moment of COVID-19 vaccination injection were also recorded to collect data about the main feelings connected to the vaccination decision-making process. Data were collected between 19 March 2021 and 21 April 2021. The most effective motivational incentives were the beliefs that vaccination helped protect vulnerable members of the community (97.5% agreement), could protect one's own health (93.7%), health authorities could be trusted (58.7%), and the vaccine had been rigorously tested (53.8%). Actual personal exposure to COVID was less important (reported importance agreement 16-24%), and the influence of news and social media was still lower (4-6%). Differences between physicians' and other HCPs' ratings were also found. Finally, emotional status at vaccination showed high ratings for positive emotions surrounding the vaccination act. This study provided additional evidence about the multifaceted motivations behind COVID-19 vaccine acceptance and showed the potential of understanding the psychosocial roots of vaccine behaviors for shaping public communication campaigns. The highly emotionally charged response obtained underscores the importance of strengthening the community feeling among HCPs.

Vaccination Attitudes and Experiences of Medical Doctors in Croatia amid the COVID-19 Pandemic: A Social Roles Conflict?

The study aimed to investigate the range of experiences and attitudes of Croatian medical doctors (MDs) related to vaccination and vaccine hesitancy. In January 2021 three asynchronous online focus groups were held using MRQual, a web-based platform, which included 46 MDs from all three levels of the healthcare system in Croatia. NVivo, a qualitative data analysis software package, was used for the thematic analysis of collected data. The participants expressed a high level of support for the Croatian immunization program and vaccines in general. However, some skepticism was expressed regarding new vaccines and the regulatory processes of their approval. A significant number of participants raised concerns over the approval of COVID-19 vaccines, especially given their rapid development. The results also revealed that the process of communication with patients is often based on the very elaborate categorizations of patients based on previous experience, which leads to prioritizing and a communication breakup when dealing with “problematic patients”. MDs find themselves in a delicate situation where a fine balance between time-consuming communication with patients and the demands for maintaining satisfying vaccination uptake is needed. The situation arises from a social roles conflict that is embedded in wider social values and expectations, since communication problems do not arise in the doctor’s office, and therefore cannot be solved without addressing the social forces that cause trust deficiencies. To achieve better immunization results public health leaders need to better understand the social contexts and constraints of MDs vaccine-related behaviors.

Improving knowledge and trust in vaccines: A survey-based assessment of the potential of the European Union Clinical Trial Regulation No 536/2014 plain language summary to increase health literacy

The European Clinical Trial Regulation No 536/2014 is the first mandate for a non-technical, publicly disclosed, plain language summary (PLS) of clinical trial results. This easy-to-understand summary has the potential to inform the public about clinical trial results and thereby improve health literacy in vaccines. To investigate the utility of the PLS, we undertook 2 online surveys (July/October 2020) in the United Kingdom, the United States and India. Participants were selected by quota sampling to ensure representation of gender, age and parental status. Those lacking interest in vaccine clinical research were excluded. In survey 1, participants were questioned about their interest in and expectations of vaccine trial results. In survey 2, the perceptions of participants to a range of written communication styles used in publicly available PLSs were evaluated. A total of 66 (13%) and 122 (29%) individuals were excluded solely due to lack of interest in vaccine clinical research in surveys 1 and 2, respectively; 450 respondents (150/country) completed survey 1 and 300 (100/country) completed survey 2. In survey 1, there was a correlation (p < 0.01) between claimed knowledge of and trust in vaccines. Healthcare professionals were the most trusted source for vaccine information, while vaccine companies were ranked relatively low. In survey 2, infographic PLS formats were considered easiest to understand, most engaging and the strongest communicators. Emphasizing the main points of the infographics in the text did not improve comprehension or recall. Most respondents (86%) indicated that they would like to see this type of communication in the future. Overall, this research suggests that the PLS, by optimizing content and format, has a potential to increase health literacy, and thereby, as part of a wider integrated communication strategy, build vaccine knowledge and confidence.

Hesitação e recusa vacinal em países com sistemas universais de saúde: uma revisão integrativa sobre seus efeitos

RESUMO O número de indivíduos que recusam ou hesitam a vacinação vem crescendo nos últimos anos em diversos países, e isso tem sido notado com a diminuição da cobertura vacinal. Diante desse cenário, faz-se necessário conhecer quais os efeitos que esses fenômenos têm trazido para os sistemas universais de saúde. O estudo objetivou revisar os efeitos da recusa/hesitação vacinal para a população de países com sistemas universais de saúde, na produção científica da área da saúde. Realizou-se uma revisão integrativa nas bases de dados Lilacs, SciELO, PubMed/Medline, Scopus e Embase. Identificou-se o total de 318 publicações, realizou-se revisão sistematizada e ordenada, permanecendo para leitura completa 12 artigos científicos. Verificaram-se sete categorias de abordagem do tema: 1) políticas públicas para imunização da população; 2) fatores da hesitação da vacinação contra gripe; 3) hesitação entre profissionais de saúde; 4) fatores importantes para a decisão dos pais de vacinarem; 5) segurança das vacinas; 6) determinantes sociais, demográficos e econômicos para hesitação/recusa; e 7) projeção de cobertura vacinal para o futuro e política de vacinação. Os artigos científicos estudados permitiram entender como se dá a recusa e a hesitação vacinal em diferentes cenários, os seus efeitos e como esses motivos estão interligados entre si.

Two years of on-site influenza vaccination strategy in an Italian university hospital: main results and lessons learned

Although the vaccination of healthcare workers (HCWs) is considered essential for preventing influenza circulation in the hospital setting, vaccination coverage (VC) in this group remains low. Among the reasons cited by HCWs is a lack of time to attend the vaccination clinic. For the 2018/2019 influenza season, active (on-site) influenza vaccination was offered directly in 44 operative units (OUs) of the Bari Policlinico hospital (50 OUs, 3,397 HCWs). At the same time, the hospital granted the HCW access to the vaccination clinic during October and December 2018. VC achieved among HCWs of Bari Policlinico during the 2018/2019 influenza season was then analyzed, and the results compared with those of the 2017/18 season. During the 2018/19 season, VC was 20.4% (n = 798) and thus higher than the 14.2% of the 2017/18 season (+6.2%). The highest VC was among physicians (33.4%), followed by other HCWs (23.8%), auxiliary staff (8.6%), and nurses (7.2%). Overall, 284 (36.5%) HCWs were vaccinated at on-site sessions. Multivariate analysis showed that vaccination uptake was associated with male gender and with work in OU where vaccination was actively offered. On the other hand, being a nurse or auxiliary staff member and working in the surgical area were deterrents. Although VC remained unsatisfactory, active on-site vaccination proved to be an important strategy to improve vaccination compliance, increasing 44% compared to the previous season. Nonetheless, mandatory vaccination directed by public health institutions may be the only way to reach a minimum level of coverage.

Promoting Influenza Vaccination among Staff of Nursing Homes According to Behavioral Insights: Analyzing the Choice Architecture during a Nudge-Based Intervention

(1) Background: Influenza vaccination uptake in nursing home (NH) workers is uncommon. The aim of this study was to understand the choice architecture of influenza vaccination acceptance or refusal among them and to promote vaccination acceptance using the nudge approach. (2) Methods: In autumn 2019, a nudge intervention with a contextual qualitative analysis of choice architecture of vaccination was performed among the staff of eight Tuscan NHs. In summer 2020, a cross-sectional study including the staff of 111 NHs (8 in the nudge, 103 in the comparison group) was conducted to assess the impact of the nudge intervention in promoting vaccination uptake. (3) Results: Macro-categories of motivations for vaccination uptake that emerged from the qualitative analysis were risk perception, value dimension, and trust, while those regarding refusal were risk perception, distrust, value dimension, and reasons related to one’s health. Considering the cross-sectional study, influenza vaccination uptake in the 2018–2019 season was similar in the two groups (23.6% vs. 22.2% respectively, in the nudge and comparison group), but significantly different in the 2019–2020 season: 28% in the nudge vs. 20% in the comparison group. Also, the intention to get the vaccine in the 2020–2021 season was significantly different in the two groups: 37.9% in the nudge and 30.8% in the comparison group. (4) Conclusions: Nudge interventions-simple, fast, low cost-could be effective in promoting vaccination acceptance among NH workers and the analysis of choice architecture could be useful in improving tailored, new nudge interventions aimed at modifying irrational biased and cognitive errors.

Health Literacy, Vaccine Confidence and Influenza Vaccination Uptake among Nursing Home Staff: A Cross-Sectional Study Conducted in Tuscany

The aim of this cross-sectional study is to address whether health literacy (HL) and vaccine confidence are related with influenza vaccination uptake among staff of nursing homes (NHs). It was conducted in Tuscany (Italy) in autumn 2018, including the staff of 28 NHs. A questionnaire was used to collect individual data regarding influenza vaccination in 2016–2017 and 2017–2018 seasons; the intention to be vaccinated in 2018–2019; as well as demographic, educational, and health information. It included also the Italian Medical Term Recognition (IMETER) test to measure HL and eight Likert-type statements to calculate a Vaccine Confidence Index (VCI). The number of employees that fulfilled the questionnaire was 710. The percentage of influenza vaccination uptake was low: only 9.6% got vaccinated in 2016–2017 and 2017–2018 and intended to vaccinate in 2018–2019. The VCI score and the IMETER-adjusted scores were weakly correlated (Rho = 0.156). At the multinomial logistic regression analysis, the VCI was a positive predictor of vaccination uptake. In conclusion, vaccine confidence is the strongest predictor of influenza vaccination uptake among the staff of NHs. The development of an adequate vaccine literacy measurement tool could be useful to understand whether skills could be related to vaccine confidence.