Vaccine education and promotion

Edited by Graça S. Carvalho and Carlos Alberto De Oliveira Magalhães Júnior Published in Frontiers in Public Health Vaccine education and promotion May 2025 Frontiers in Public Health 1frontiersin.org About Frontiers Frontiers is more than just an open access publisher of scholarly articles: it is a pioneering approach to the world of academia, radically improving the way scholarly research is managed. The grand vision of Frontiers is a world where all people have an equal opportunity to seek, share and generate knowledge. Frontiers provides immediate and permanent online open access to all its publications, but this alone is not enough to realize our grand goals. Frontiers journal series The Frontiers journal series is a multi-tier and interdisciplinary set of openaccess, online journals, promising a paradigm shift from the current review, selection and dissemination processes in academic publishing. 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ISSN 1664-8714 ISBN 978-2-8325-6337-3 DOI 10.3389/978-2-8325-6337-3 May 2025 Frontiers in Public Health 2frontiersin.org Vaccine education and promotion Topic editors Graça S. Carvalho — University of Minho, Portugal Carlos Alberto De Oliveira Magalhães Júnior — State University of Maringá, Brazil Citation Carvalho, G. S., Júnior, C. A. D. O. M., eds. (2025). Vaccine education and promotion. Lausanne: Frontiers Media SA. doi: 10.3389/978-2-8325-6337-3 May 2025 Frontiers in Public Health 3frontiersin.org 07 Editorial: Vaccine education and promotion Graça S. Carvalho and Carlos Alberto de Oliveira Magalhães Júnior 11 “Let’s get back to normal”: emotions mediate the effects of persuasive messages on willingness to vaccinate for COVID-19 Krista R. Muis, Panayiota Kendeou, Martina Kohatsu and Shuting Wang 23 Vaccine communication strategies among healthcare workers as a reflection of the Israeli Ministry of Health’s communication strategies before and after the COVID-19 pandemic Rana Hijazi, Anat Gesser-Edelsburg and Gustavo S. Mesch 34 Determinants of influenza non-vaccination among Canadian children: insights from a nationwide survey Abdallah Alami, Sailly Dave, Caren Uhlik, Marwa Ebrahim, Daniel Krewski and Julie Laroche 47 Spatiotemporal analysis of HPV vaccination and associated neighborhood-level disparities in Texas—an ecological study Ryan Ramphul, Abigail S. Zamorano, Saswati Upadhyay, Manali Desai and Cici Bauer 55 Determinants of pneumococcal vaccination dropout among children aged 12–23 months in Ethiopia: a secondary analysis from the 2019 mini demographic and health survey Ayenew Assefa, Teklehaimanot Kiros, Mulat Erkihun, Aynework Abebaw, Ayenew Berhan and Andargachew Almaw 63 Exploring the relationship between vaccine hesitancy and mothers’ perspectives on COVID-19 vaccines for children ages 5–11 years during the omicron predominant period 2021–2022: a qualitative study Tiffany A. Suragh, David Adzrago, Marlyn A. Allicock, Paul G. Yeh and Paula Cuccaro 72 Community Health Volunteers’ experiences of implementing COVID-19 vaccine education and promotion in Kenya: a qualitative descriptive study Constance S. Shumba, Peterson Kiraithe, Isabel Kambo and Sheila Shaibu 82 One Health education for criticality on vaccination in teacher training Inés Martínez-Pena, Blanca Puig and Araitz Uskola 94 Pregnant individuals perspectives towards receiving COVID-19 vaccination during their pregnancy: an in-depth qualitative study Sanne J. M. Zilver, Anna L. Rietveld, Noralie N. Schonewille, Petra C. A. M. Bakker, Birit F. P. Broekman, Elisabeth van Leeuwen and Christianne J. M. de Groot Table of contents May 2025 Frontiers in Public Health 4frontiersin.org 104 Investigating the influencing factors of vaccination decisions for newly developed and established vaccines: a comparative study based on latent class logit models in China Shiyun Chang, Biao Xu, Hailing Xi and Yifan Shao 117 Corrigendum: Investigating the influencing factors of vaccination decisions for newly-developed and established vaccines: a comparative study based on latent class logit models in China Shiyun Chang, Biao Xu, Hailing Xi and Yifan Shao 118 Understanding herpes zoster vaccine hesitancy and information asymmetry: a qualitative study in China Xiaolong Wang, Yufei Xing, Enming Zhang, Zhengyue Dai, Yuan Li, Shuhui Shang, Jiale Hu, Xian Zhang and Qiong Fang 129 Awareness of HPV and HPV vaccine among college students in China Manman Li, Fengzhi Zhang, Yun Shi, Kaige Shi, Xiaoxue Li and Hua Bai 136 Role of community engagement in advancing vaccine equity Samantha Smith, Erika Marquez, Amanda Haboush-Deloye, Tiana Tu, Aaliyah Goodie and David Perez 144 Connecting the experiences of persons with disabilities and social workers in Nigerian care institutions regarding COVID-19 vaccine uptake: a qualitative descriptive-interpretive design Farah Naz Rahman, Anthony Obinna Iwuagwu, Christopher Ndubuisi Ngwu, Michael Ebe Kalu, Amani Kasherwa, Mohammad Rocky Khan Chowdhury and Manzur Kader 157 Uptake and correlates of influenza vaccine among older adults residing in rural regions of south China: a cross-sectional study Peizhen Zhao, Wenqian Xu, Jinshen Wang, Peng Liang, Haiyi Li and Cheng Wang 166 Information needed for optimal immunization related to medical advice: an observational prospective cohort study protocol (INFORMed) Jennifer Wrenger, Bettina Berger, David D. Martin and Ekkehart Jenetzky 173 Can social media promote vaccination? Strategies and effectiveness of COVID-19 vaccine popularization on Chinese Weibo Jing Xu, Difan Guo, Jing Wu and Jinghong Xu 182 Understanding student engagement in vaccination education: an interview-based multi-stakeholder study Melissa Schlopsna and Annette Scheersoi May 2025 Frontiers in Public Health 5frontiersin.org 198 Vaccination: a look at the social representations of Brazilian children Suelen de Gaspi, Carlos Alberto de Oliveira Magalhães Júnior, Rosa Branca Tracana, Eduarda Maria Schneider and Graça S. Carvalho 206 Lessons learned from the COVID-19 pandemic: identifying hesitant groups and exploring reasons for vaccination hesitancy, from adolescence to late adulthood Laure Pauly, Caroline Residori, Hamid Bulut, Dmitry Bulaev, Soumyabrata Ghosh, Marc P. O’Sullivan, Joëlle V. Fritz, Michel Vaillant, Basile Rommes, Robin Samuel, Venkata P. Satagopam, Rejko Krüger and Anja K. Leist on behalf of the CON-VINCE Consortium and the ORCHESTRA Working Group 220 Examining psychological correlates of vaccine hesitancy: a comparative study between the US and Israel Nicolle Simonovic, Anat Gesser-Edelsburg and Jennifer M. Taber 231 Exploring factors influencing childhood immunization status in East Africa using multilevel ordinal logistic regression analysis Aster Addisu Dires, Demeke Lakew Workie and Abay Kassa Teklie 242 The influence of factors related to public health campaigns on vaccination behavior among population of Wuxi region, China Yang Ye and Anselm Ting Su 257 From classrooms to real-world contexts: enhancing vaccine education through open schooling Hannah Kwella, Jana Schilbert, Amélie Tessartz and Annette Scheersoi 269 Health belief model of parents’ COVID-19 vaccination intentions for children: perceived benefits and barriers in Indonesia Eka Wuri Handayani, Dyah Aryani Perwitasari and Fredrick Dermawan Purba 277 Analysis of factors influencing HPV vaccination intention among Chinese college students: structural equation modeling based on health belief theory Shi-Yuan Song, Ying Guo, Yi-Hua Li, Zheng Wang and Wei Gao 295 Sociodemographic disparities in influenza vaccination among older adults in United States Huan Tao, Jin Chen, Xue Zhang, Tao Wang, Nenggang Jiang and Yongqian Jia May 2025 Frontiers in Public Health 6frontiersin.org 303 Community-engaged curriculum development using racial justice and biomedical lenses to address COVID-19 vaccine hesitancy in black individuals with rheumatologic conditions Eseosa Olive Osaghae, Greta Sirek, Tonya Roberson, Mia Chandler, Ariel Childs, Monica Crespo-Bosque, Gina Curry, Amar Dhand, Mary Dollear, Alice Eggelston, Nnenna Ezeh, Dieufort Fleurissaint, Denice Garrett, Gail Granville, Muriel Jean-Jacques, Elena Losina, Holly Milaeger, Lutfiyya Muhammad, Mary Ann Nelson, Chisa Nosamiefan, Bisola Ojikutu, Neil Pillai, Mary Beth Son, Marie Jacques Toussaint, Ana Valle, Jessica N. Williams, Michael York, Karen Mancera-Cuevas, Candace H. Feldman and Rosalind Ramsey-Goldman 312 Comparative analysis of the role of healthcare beliefs on childhood vaccination uptake among parents in Malaysia and Singapore during the COVID-19 pandemic Jia Ming Low, Erwin Jiayuan Khoo, Meow Keong Thong, Chloe Soo, Anh Phuong Tran, Le Ye Lee and Fook Choe Cheah TYPE Editorial PUBLISHED 29 April 2025 DOI 10.3389/fpubh.2025.1610968 OPEN ACCESS EDITED AND REVIEWED BY Christiane Stock, Institute of Health and Nursing Science, Germany *CORRESPONDENCE Graça S. Carvalho [email protected] RECEIVED 13 April 2025 ACCEPTED 14 April 2025 PUBLISHED 29 April 2025 CITATION Carvalho GS and J´ unior CAdOM (2025) Editorial: Vaccine education and promotion. Front. Public Health 13:1610968. doi: 10.3389/fpubh.2025.1610968 COPYRIGHT ©2025 Carvalho and J´ unior. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Editorial: Vaccine education and promotion Graça S. Carvalho1*and Carlos Alberto de Oliveira Magalh˜ aes J´ unior2 1Research Centre for Child Studies, University of Minho, Braga, Portugal, 2State University of Maringá, Maringá, PR, Brazil KEYWORDS determinants of vaccination, vaccination hesitancy, vaccination among students, health education, health promotion Editorial on the Research Topic Vaccine education and promotion This editorial highlights key developments in the Public Health Research Topic “Vaccine education and promotion.” This critical area aims to inform and encourage vaccination by providing accurate scientific information and implementing effective vaccination programs, emphasizing their benefits, safety, and role in preventing infectious diseases. A total of 39 manuscripts were submitted for consideration. Following a rigorous peer-review process and revisions based on expert feedback, 29 (74.3%) were accepted for publication. Among these, 14 explore the determinants of vaccination, eight examine vaccine hesitancy and seven address vaccination among students. 1 Determinants of vaccination The determinants of vaccination are diverse but can be broadly categorized into three groups (1): (i) Contextual factors, including historical, socio-cultural, environmental, health system/institutional, economic, and political influences; (ii) Individual and group influences, such as perceptions of vaccines and the impact of social or peer environments; (iii) Vaccineand vaccination-specific Research Topic, factors directly related to the vaccine or the act of vaccination itself. Vaccination uptake also varies across risk populations, with distinct determinants potentially influencing behavior in each group (2). As such, a thorough understanding of these factors is essential for designing targeted interventions to improve immunization coverage (3). The 13 papers included in this section, Determinants of Vaccination, are organized across three Research Topic: 1.1 Seven papers look at communication and engagement for vaccination Chang et al. compared USA public vaccination decisions for newly-developed and established vaccines, and recognized the need for clear communication and community engagement as critical strategies for addressing public concerns and misinformation; Frontiers in Public Health 01 frontiersin.org 7 Carvalho and J´ unior 10.3389/fpubh.2025.1610968 Rahman et al. looked at the perceptions of Nigerian persons with disabilities regarding the COVID-19 pandemic and the vaccine and identified the need for culturally and religiously sensitive communication strategies, and tailored educational programs by social workers; Xu et al. analyzed “vaccine science popularization” in the Chinese social media Weibo during the COVID-19 pandemic where publishers were divided into individuals, organizations, media, government, and scientists, and verified that Weibo scientists’ arguments were those that more positively influenced the effect of vaccine popularization; Hijazi et al. identified the Israeli Ministry of Health communication strategies regarding vaccines during COVID-19 pandemic and how healthcare workers shaped their professional socialization processes within the health system, leading to a reliance on established communication strategies and informational channels; Shumba et al. analyzed community health volunteers experiences of implementing COVID-19 Vaccine education and promotion in Kenya during the pandemic, showing they contributed to the high uptake of primary vaccines and boosters; Wrenger et al. used a protocol (INFORMed) in Germany to identify the wish for advice in hesitant and no-hesitant new-born’s parents and the comparison of parents in terms of their respective information needs; and Smith et al. addressed a community engagement framework that can provide a roadmap to navigate the dynamic and multifaceted nature of equity-related work by paving the way for meaningful interventions to mitigate health disparities. 1.2 Four papers look at socioeconomics discrepancy Tao et al. found substantial racial and socioeconomic disparities in influenza vaccination uptake among United States adults aged 65 years or older; Zhao et al. investigated the extent of influenza vaccine coverage in south China adults aged 60 years or older and identified the factors influencing vaccine uptake; Ramphul et al. identified areas in Texas, USA, with high and low HPV vaccination rates and explored differences in neighborhood characteristics, showing that vaccination coverage rates depend on the community’s income level; and Ye and Ting Su explored the factors related to public health campaigns, in Wuxi region of China, that can improve vaccination rates in low socioeconomic groups and rural areas, to contributing to better public health strategies. 1.3 Three papers look at children’s immunization Alami et al. analyzed the Canadian survey about parents/guardians’ perspectives on influenza immunization and identified the main factors influencing low rates of children’s vaccination, such as residing in rural areas, lower parental education and lower household income; Dires et al. looked at the factors influencing childhood immunization status in East Africa, which varied among countries and regions, and found that mothers attending antenatal care played a key role in children’s vaccination; and Assefa et al. evaluated the determinants of pneumonia conjugate vaccine (PCV) dropout among children aged 12–23 months in Ethiopia and identified the significant factors influencing PCV dropout, such as having a health card, having received the PCV 2 vaccinations, and region. 2 Vaccination hesitancy Vaccine hesitancy refers to the delay in acceptance or outright refusal of vaccines despite the availability of vaccination services; it is a complex and context-specific phenomenon that varies across time, location, and type of vaccine (4). It has been linked to declining vaccination coverage and a heightened risk of outbreaks and epidemics of vaccine-preventable diseases (5). The eight papers in the Vaccination Hesitancy section are distributed across two Research Topic: 2.1 Five papers address vaccination hesitancy in the community Osaghae et al. leveraged long-standing communityacademic partnerships in two cities to develop a curriculum for interventions to decrease COVID-19 vaccine hesitancy within Black communities in the USA; Muis et al. examined the effectiveness of three different messages for persuading Canadian individuals to get vaccinated against COVID-19, and the role that emotions play in persuasion, verifying that emotions mediated relations between vaccine confidence/hesitancy and willingness; Pauly et al. identified COVID-19 vaccine hesitant groups from adolescence to late adulthood and explored their motivations for and against vaccination in a nationwide Luxembourgish population, being the vaccination hesitancy higher in the younger age groups; Zilver et al. studied barriers and facilitators for Netherlander pregnant women’s choice and motivation regarding vaccination against COVID-19 during pregnancy, verifying that they needed clear, unambiguous information concerning health consequences, particularly for their offspring; and Wang et al. conducted a qualitative survey using Vaccine Hesitancy Determinants Matrix and 5C model to understand and improve Herpes zoster vaccination rates among middle-aged and older adults in China. 2.2 Three papers address parents’ vaccination hesitancy Low et al. investigated parents’ vaccine hesitancy rates in Malaysia and Singapore, and explored whether these rates were associated with parents’ health beliefs, having found that the prevalence of perceived parental vaccine hesitancy was higher in Malaysia; Handayani et al. conducted a study in Indonesia aiming to develop guidance for in-depth interviews for a future qualitative study based on a cross-sectional quantitative study of parents with school-age children and found a significant association between parents’ intention to vaccinate their children and the perceived benefits and perceived barriers to vaccination; and Suragh et al. conducted a study on vaccine hesitancy among USA white parents with higher education and socioeconomic Frontiers in Public Health 02 frontiersin.org 8 Muis et al. 10.3389/fpubh.2024.1377973 Frontiers in Public Health 05 frontiersin.org the vaccine confidence subscale was 0.86, and 0.73 for the vaccine hesitancy subscale. Experimental texts Three experimental texts were developed based on content from the Centers for Disease Control website on COVID-19 vaccinations.1 Except for the personal message component, all features of the texts were identical (e.g., used persuasive language, the same credible sources, and written to bepersonally relevant). The first 68 words were the same across all three texts, which began by providing basic information about COVID-19 and stating how contagious COVID-19 is. The texts then described it as a serious threat and recommended that the threat should betaken seriously to prevent further spread. The texts then presented information with regards to vaccines, their safety and efficacy, and then provided encouragement to get vaccinated. The key differences between the three texts were minor wording that focused on protecting oneself (self-interest), protecting oneself and others (self-interest + altruistic), or protecting oneself and others as well as getting back to a normal life (self-interest + altruistic + normal). For example, for the text that focused on protecting oneself, following the information on how contagious the virus is, the text stated, “This means COVID-19 is a serious threat to you,” whereas the other two texts stated, “This means COVID-19 is a serious threat to youand your community.” As another example, the text that focused on personal protection stated, “COVID-19 vaccination helps protect you from getting sick or severely ill with COVID-19” whereas the other two texts stated, “COVID-19 vaccination will help protect you from getting sick or severely ill with COVID-19 and will help protect your loved ones and the people around you. That is, even if youdo get COVID-19 after being vaccinated, it may also prevent youfrom spreading it to others.” Finally, for the text that focused on getting back to normal, the text added the following, “People who have been fully vaccinated can start to do some things that they had stopped doing because of the pandemic. Countries like the UK and Israel are getting back to their normal life because everyone is doing their part and getting vaccinated. To stop this pandemic, everyone will need to get vaccinated. This is the only way wewill beable to get back to a normal life. Protect yourself and others from COVID-19. Let’s get back to normal!” All texts then ended with “Do not wait. Vaccinate!” and were followed by a pamphlet that highlighted the main message (i.e., protect oneself; protect oneself and others; protect oneself and others, and let’s get back to normal). See Appendix A for the texts and pamphlets. Total word count for the texts were 172, 224, and 298, respectively, with a Flesch reading ease score of 46.3, and a Flesch– Kincaid grade level of 9.9 for all three texts. Emotions A self-report questionnaire consisting of five items was used to measure participants’ emotions toward COVID-19 vaccines. Each item consisted of a single word (e.g., “Happy”) and participants were asked to report the intensity of their emotional response to COVID-19 vaccines (control condition) after they read the text (text conditions). Single-item measures have demonstrated to be psychometrically sound substitutes for multi-item scales when administration time is 1 https://www.cdc.gov/coronavirus/2019-ncov/vaccines/index.html short [e.g., (52)]. Intensity was reported using a 5-point Likert scale using the following labels: Not at all (1), Very little (2), Moderate (3), Strong (4), and Very Strong (5). The five emotions included: joy, hope, empathy, relief, and anger. Willingness to get a COVID-19 vaccine A seven-item measure was developed to assess participants’ willingness to get a COVID-19 vaccine (e.g., “In light of the COVID-19 outbreak, Iamwilling to…”). Participants were asked to rate their willingness using a sliding rating scale that ranged from 0 “Not at all willing to do this” to 100 “Very willing to do this,” with 50 “Moderately willing to do this” as the middle marker. The first item assessed general willingness to get a COVID-19 vaccine (e.g., “Get a COVID-19 vaccine”), along with more specific options including choice of vaccine (e.g., “Get a COVID-19 vaccine if Ican choose which one Iget”), no choice (e.g., “Get a COVID-19 vaccine even if Icannot choose which one Iget”), and then willingness to get a specific vaccine currently available in Canada (e.g., “Get the Pfizer/ Moderna/AstraZeneca/Johnson and Johnson vaccine for COVID19”). Chronbach’s alpha reliability for the seven-item scale was 0.90. Demographic information Participants reported their age, sex, first language spoken, highest level of education completed, current health status (ranging from poor to excellent), what health issues they have, how frequently they get the flu vaccine, current employment status, essential worker status, marital status, annual income, residence location (e.g., postal code; urban, suburban, or rural area, etc), number of parents/children/ individuals living with them, political affiliation, strength of political affiliation for social issues, strength of political affiliation for economic issues, time spent per day following information about COVID-19, sources of that information (e.g., CBC, Facebook, Fox News, RadioCanada, CNN), and religiosity (e.g., religious affiliation and strength of beliefs). Procedure After obtaining ethics approval from the Research Ethics Board (REB), participants were recruited through MTurk and via a snowball sampling technique through social media (Facebook). A link was provided to Qualtrics (on MTurk and Facebook, housed by our university to ensure encrypted procedures were strictly followed), which was the platform used for collecting data. Participants names were not collected to ensure anonymity and all information was stored on a secure, locked computer with double authentication measures to ensure confidentiality. Only the first author had access to the data, which was all in numerical form. Participants first consented, after which they completed the vaccine confidence and hesitancy questionnaire. Participants were then randomly assigned to one of four conditions: protect yourself “self-interest” condition; protect yourself and others “self-interest + altruistic” condition; protect yourself, others, and let’s get back to normal “self-interest + altruistic + normal” condition; or the control condition (no persuasive message). After reading (or not in the case of the control condition), participants reported their emotions about COVID-19 vaccines followed by their willingness to get a COVID-19 vaccine. Participants then completed the demographics questionnaire after which they were 15 Muis et al. 10.3389/fpubh.2024.1377973 Frontiers in Public Health 06 frontiersin.org paid for their time (MTurk) or were entered into a draw to win $100 (with a chance of winning being 1in 50). To beentered into the draw, participants recruited through Facebook were provided the first author’s email and were asked to contact the first author with a randomly generated code provided at the end of the survey. Participants in the control condition spent approximately 10 min completing the survey, whereas participants in the text conditions spent approximately 12 min (self-interest) to 13 min (self-interest + altruistic, and self-interest + altruistic + normal) completing the survey and reading the texts. Results Preliminary data screening and analyses Prior to conducting analyses, it was first necessary to check for normality and outliers, and whether groups differed on concern, vaccine confidence, and vaccine hesitancy. As expected, most variables were skewed due to the nature of the items, which is common in research on vaccine hesitancy and in research on emotions [see (32)]. Moreover, as expected, there were no differences between groups on concern about COVID-19, F(3, 325) = 1.08, p > 0.05, vaccine confidence, F(3, 325) = 2.19, p > 0.05, or vaccine hesitancy, F(3, 325) = 1.23, p > 0.05. Table1 reports means and standard deviations for willingness to get vaccinated and emotions as a function of condition, and Table2 reports correlations between all variables. Sample characteristics for vaccine hesitancy To assess whether our sample of vaccine hesitant/resistant individuals was consistent with previous literature (3, 13–15), wefirst identified whether individuals were hesitant/resistant or not. Based on participants’ score on vaccine hesitancy (i.e., an average score higher than 3, the neutral point on the scale), participants were coded as vaccine hesitant/resistant (23%) or vaccine confident (77%). Consistent with previous research, individuals who were vaccine hesitant/resistant were primarily female (62%), Catholic (25%), moderately to extremely religious (47%), but also identified mostly to the Liberal Party of Canada (46%). Interestingly, there were no differences in vaccine hesitancy between those sampled from MTurk and those from Facebook (χ2 = 2.94, df = 1, p = 0.09) and individuals who were vaccine hesitant did not differ in their information sources for COVID-19 from those who were vaccine confident. For both groups, 22% obtained their information from CBC News (the most frequent source). Moreover, regression analyses revealed that vaccine hesitancy was not predicted by age (p = 0.62), health status (ranging from poor to excellent; p = 0.72), number of health issues (p = 0.96), level of concern about the pandemic (p = 0.21), or level of education (p = 0.40). However, level of religiosity was a significant positive predictor wherein stronger religious beliefs predicted more hesitancy, β = −0.27, p < 0.001. Effect of persuasive messages on willingness to get vaccinated To examine the first research question, whether groups differed on willingness to get vaccinated as a function of type of persuasive message and hesitancy, using concern as a covariate, ANCOVA results revealed a main effect of text condition, F(3, 325) = 2.80, p = 0.04, η2 = 0.03, a main effect of hesitancy group, F(1, 325) = 70.54, p < 0.001, η2 = 0.18, but no interaction, F(3, 325) = 1.07, p > 0.05. As hypothesized, individuals who were confident in vaccines were more willing to get vaccinated than those who were hesitant/resistant (Hypothesis 3). Follow-up post hoc analyses using LSD revealed that individuals in the self-interest + altruistic + normal condition were more willing to get vaccinated compared to the control condition TABLE1 Means and standard deviations for willingness to get vaccinated and emotions as a function of text condition and hesitancy. Control (n = 86) Self-interest (n = 76) Self-interest + Altruistic (n = 84) Personal + Altruistic + Normal (n = 79) Vaccine confident Willingness 75.94 (23.92) 85.43 (14.88) 75.20 (25.46) 84.45 (20.80) Joy 3.32 (1.18) 3.95 (0.97) 3.72 (1.08) 4.22 (0.89) Hope 3.61 (1.07) 4.24 (0.82) 4.05 (0.93) 4.25 (0.84) Empathy 2.75 (1.26) 3.13 (1.29) 3.00 (1.26) 2.84 (1.40) Relief 3.27 (1.21) 3.93 (0.99) 3.67 (1.10) 3.87 (1.02) Anger 1.85 (1.03) 1.50 (0.94) 1.50 (0.89) 1.65 (0.88) Vaccine hesitant/Resistant Willingness 52.93 (29.09) 49.14 (28.92) 47.39 (35.22) 63.64 (25.52) Joy 2.67 (1.24) 2.60 (0.99) 2.88 (1.50) 3.69 (1.08) Hope 3.04 (1.16) 3.13 (1.06) 3.05 (1.43) 3.75 (1.00) Empathy 2.70 (1.45) 2.40 (1.18) 2.94 (1.47) 2.43 (1.50) Relief 2.62 (1.13) 2.73 (0.96) 2.94 (1.29) 3.43 (0.96) Anger 2.29 (1.26) 2.46 (1.18) 2.29 (1.35) 2.18 (1.10) Standard deviation is in (brackets). 16 Muis et al. 10.3389/fpubh.2024.1377973 Frontiers in Public Health 07 frontiersin.org (p = 0.004) and self-interest + altruistic condition (p = 0.004) (Hypothesis 1). However, counter to our hypothesis, there were no differences in willingness between the self-interest + altruistic + normal condition and the self-interest condition. Similarly, individuals in the self-interest condition were more willing to get vaccinated compared to individuals in the self-interest + altruistic condition (p = 0.02) and control condition (p = 0.02) (Hypothesis 2). Finally, counter to our hypothesis, individuals in the self-interest + altruistic condition did not differ on willingness compared to the control condition (p > 0.05). We further explored whether vaccine type mattered, and whether choice or no choice as to which vaccine individuals received mattered with regard to messaging and willingness. Indeed, despite large differences in willingness across the various vaccines (particularly high willingness for Pfizer and Moderna, but low for Astrazeneca and Johnson and Johnson), the same patterns of results were replicated, with much higher willingness to get vaccinated (upward of 20%) when individuals were given the choice of which vaccine to receive compared to when they were not given a choice. Effect of persuasive texts on emotions For the second research question, whether emotions differed as a function of text condition and hesitancy, for joy, ANCOVA results revealed a significant main effect of text condition, F(3, 325) = 7.92, p < 0.001, η2 = 0.07, a main effect of hesitancy group, F(1, 325) = 33.23, p < 0.001, η 2 = 0.10, but no interaction, F(3, 325) = 1.63, p > 0.05. As hypothesized, individuals who were vaccine confident expressed more joy in relation to the COVID-19 vaccine compared to individuals who were vaccine hesitant/resistant (Hypothesis 5). Post hoc follow-up analyses using LSD revealed that, as hypothesized, individuals in the self-interest + altruistic + normal condition expressed significantly more joy about the COVID-19 vaccine compared to individuals in the other three conditions (all p < 0.01). Individuals in the self-interest and self-interest + altruistic conditions also expressed significantly greater joy than those in the control condition (both ps < 0.01), and no differences were found in joy between individuals in the self-interested condition and the self-interested + altruistic condition (Hypothesis 4). For hope, ANCOVA results revealed a significant main effect of text condition, F(3, 325) = 4.73, p = 0.003, η 2 = 0.04, a main effect of hesitancy group, F(1, 325) = 35.67, p < 0.001, η 2 = 0.10, but no interaction, F(3, 325) = 1.27, p > 0.05. As hypothesized, individuals who were vaccine hesitant/resistant were less hopeful about the vaccine than those who were vaccine confident. Post hoc follow-up analyses using LSD revealed that there were no differences between the three persuasive text conditions on hope, but that individuals in all text conditions were significantly more hopeful than individuals in the control condition (all p < 0.001). For empathy, ANCOVA results revealed no significant effects or interactions (all p > 0.05). For relief, ANCOVA results revealed a significant main effect of text condition, F(3, 325) = 4.16, p = 0.007, η2 = 0.04, a main effect of hesitancy group, F(1, 325) = 25.95, p < 0.001, η2 = 0.08, but no interaction, F(3, 325) = 1.08, p > 0.05. As hypothesized, individuals who were vaccine hesitant/resistant were less relieved about the vaccine than those who were vaccine confident. Post hoc follow-up analyses using LSD revealed that there were no differences between the three persuasive text conditions on relief, but that individuals in all text conditions were significantly more relieved than individuals in the control condition (all p < 0.001). Finally, for anger, ANCOVA results revealed no main effect of text condition, F(3, 325) = 0.37, p > 0.05, but a main effect of hesitancy group, F(1, 325) = 24.63, p < 0.001, η 2 = 0.07, and no interaction, F(3, 325) = 0.76, p > 0.05. As hypothesized, individuals who were vaccine hesitant/resistant were more angry about the vaccine than those who were vaccine confident. Relations between vaccine confidence, hesitancy, emotions, and willingness to get vaccinated To answer the last research question regarding relations between vaccine confidence, hesitancy, emotions, and willingness to get vaccinated, a path analysis using Mplus (53) was conducted (Figure1). The model revealed an excellent fit, χ 2 = 28.13, df = 3, p < 0.001, CFI = 0.96, RMSEA = 0.06 (Figure2). Vaccine confidence negatively predicted anger (β = −0.38, p < 0.001) and positively predicted joy (β = 0.41, p < 0.001), hope (β = 0.53, p < 0.001), relief (β = 0.32, p < 0.001), p < 0.001, empathy (β = 0.14, p = 0.004) and willingness to get vaccinated (β = 0.59, p < 0.001). In contrast, vaccine hesitancy positively predicted anger (β = 0.44, p < 0.001) and empathy (β = 0.14, p < 0.001), but negatively predicted joy (β = −0.38, p < 0.001), hope (β = −0.20, p < 0.001), relief (β = −0.13, p = 0.002), and willingness to get vaccinated (β = −0.60, p < 0.001). Joy also positively predicted willingness to get vaccinated (β = 0.28, p < 0.01), as did relief (β = 0.09, p < 0.05), and empathy (β = 0.08, p < 0.05), whereas anger negatively predicted willingness to vaccinated (β = −0.21, p < 0.001). Mediation TABLE2 Zero-order correlations between variables. Hesitancy Joy Hope Empathy Relief Anger Willingness Confidence −0.500** 0.56** 0.567** 0.306** 0.603** −0.277** 0.625** Hesitancy −0.46** −0.427** −0.111* −0.469** 0.366** −0.501** Joy 0.70** 0.26** 0.74** −0.45** 0.53** Hope 0.403** 0.735** −0.428** 0.493** Empathy 0.277** −0.065 0.222** Relief −0.406** 0.512** Anger −0.254** **Significant at p < 0.001. *Significant at p < 0.05. 17 Muis et al. 10.3389/fpubh.2024.1377973 Frontiers in Public Health 08 frontiersin.org analyses further revealed that anger (−0.08, p < 0.001) and relief (0.03, p = 0.04) mediated relations between vaccine confidence and willingness, whereas anger (0.09, p < 0.001) and empathy (0.02, p = 0.04) mediated relations between vaccine hesitancy and willingness. Wediscuss these results next. Discussion The purpose of this study was to examine the effects of three different types of persuasive messages on willingness to get vaccinated for COVID-19. Wealso explored the role that emotions play in social persuasion to better understand the mechanisms underlying social persuasion via text-based messages. Results revealed that consistent with hypotheses, the text that focused on getting back to normal in addition to protecting oneself and others (self-interest + altruistic + normal) was more effective in persuading individuals to get vaccinated compared to the control condition (no message) and the self-interest + altruistic condition. However, there were no differences in willingness to get vaccinated between the self-interest + altruistic + normal condition and the self-interest condition, and no differences between the control condition and the self-interest + altruistic condition. The finding that the self-interest + altruistic condition did not affect willingness to get vaccinated is counter to recent research that found that self-interest + altruistic persuasive messages were more effective in increasing individuals’ behavioral intentions like social distancing/behaviors and wearing masks compared to no persuasive message (10–12). Arguably, such social behaviors may beconstrued as relatively easy to engage in to protect others compared to getting vaccinated, particularly for those individuals who are vaccine hesitant/ resistant. As such, a message that focuses on protecting others may not be an effective way to encourage individuals to get vaccinated. However, the persuasive message about protecting oneself was just as effective in increasing individuals’ willingness to get vaccinated compared to the message that focused on getting back to normal, which also had an altruistic component to it, but only for individuals who were not vaccine resistant. To explain these results, welooked deeper into the effects of each of the messages as a function of individuals’ hesitancy toward vaccines. Vaccine hesitancy and persuasion A close examination of the effects of each type of message as a function of vaccine hesitancy group (see Table1) shows that for vaccine hesitant individuals, the only message that increased willingness to get vaccinated was “Let’s get back to normal.” Given that the other two persuasive text conditions had means lower than the control condition for individuals who were vaccine hesitant, and that the “normal” condition increased willingness by over 10% compared to the control condition, weinterpret this result as meaningful and important from a public messaging perspective. In the context of pandemic fatigue (2), to persuade vaccine hesitant/resistant individuals to get vaccinated may require a focus on getting life back to normal with regards to the removal of restrictions and regaining of individual freedoms. For vaccine confident individuals, both the self-interest condition and the self-interest + altruistic + normal condition increased willingness to get vaccinated by 10% above the control condition. These results suggest that in the context of a pandemic, individuals who are confident in vaccines are willing to protect themselves but are also wanting to get life back to normal. It may be the case that individuals were more driven to prevent themselves from getting seriously sick or dying than they were for protecting others from getting sick. Alternatively, at the time that vaccines were rolling out, it was not clear whether or to what extent the COVID-19 vaccines decreased viral load or spread of the virus and, as such, the message to protect others may not have been convincing to individuals since information was rapidly changing at that time (54). Taken together, these results suggest that context matters, and that messaging needs to betailored as a function of individuals’ beliefs about vaccines and other psychological variables like choice versus no choice. Indeed, a brief examination of the history of the anti-vaccination movement has shown that vaccine hesitancy has been around since the dawn of vaccines [see (55)]. Factors that affect vaccine hesitancy FIGURE2 Final model. 18 Muis et al. 10.3389/fpubh.2024.1377973 Frontiers in Public Health 09 frontiersin.org include complacency (perceived low risk, low general knowledge and awareness), confidence (trust in vaccine safety, the system or policy makers), convenience (availability, accessibility, affordability), calculation (engagement in gathering extensive information), and collective responsibility (willingness to protect others) (56). Historically, religious beliefs (i.e., “it is not God’s will”) and mandatory programs sparked a distrust in vaccines and riots due to restrictions on personal freedoms (57, 58). Modern-era distrust of vaccines grew from concerns over vaccine safety and efficacy, particularly after the polio vaccine was released with a live, active virus that had negative repercussions for a small proportion of children who were given the vaccine (59). Today, factors like religious beliefs, cultural beliefs, and perceptions of risk and harm continue to drive vaccine hesitancy. Prior vaccine history, perceived safety of vaccines, the impacts of vaccine mandates, political affiliation, information and misinformation on the internet, and satisfaction with government decision-making on other aspects of COVID-19 prevention or strategy management also played a significant role in the uptake of COVID-19 vaccines (60). Results from our study provide further evidence of these factors playing a role. That is, individuals with strong religious beliefs were more vaccine hesitant and were more likely to affiliate with the liberal government of Canada, which is counter to what is typically found in the US with Republicans being more vaccine hesitant (61). What is particularly noteworthy with our results is that choice mattered for individuals, regardless of whether they were vaccine confident or hesitant. Indeed, willingness to get vaccinated was 90% for individuals in the “let’s get back to normal” and “personal” conditions but dropped to 72% for those same conditions when choice of vaccine was removed. These percentages dropped to 62 and 54%, respectively, when Astrazeneca was the option, reflecting individuals’ distrust in this vaccine given news of blood clots being a risk factor. Moreover, as previously noted, for vaccine hesitant individuals, willingness was significantly higher with the message of getting back to normal than any other message, and this was particularly pronounced when they had the choice of vaccines (82% willing) versus when they did not have a choice (46% willing). Accordingly, there may have been some additive effects for vaccine hesitant individuals where the message of getting back to normal coupled with a choice of vaccine was the most powerful approach to social persuasion. To further understand the mechanisms involved in social persuasion, it is also important to consider the role of emotions. The role of emotions in persuasion Indeed, for all three persuasive message conditions, individuals felt more joy, hope, and relief than those in the control condition, with no differences in level of emotional intensity for the three persuasive message conditions (with the exception of joy). Moreover, no differences were found between persuasive text conditions and the control condition for anger or empathy. These results suggest that the persuasive messages had equal effects on increasing hope and relief, regardless of the type of persuasive message, and had no effect on empathy or anger. Most important, for the condition that included the message of getting back to normal, individuals expressed the greatest joy compared to individuals in the other three conditions. As previous empirical work has demonstrated, positive emotions, like joy, can increase effortful processing of information (33) and result in assimilation of new information into current knowledge structures (35). As such, it appears that in this context, joy played a significant role in increasing individuals’ willingness to get vaccinated, perhaps from a belief that things will get back to normal. Indeed, results from path analyses revealed that greater vaccine confidence predicted more joy, relief, hope and empathy and less anger, whereas greater vaccine hesitancy negatively predicted joy, hope, and relief, but positively predicted anger and empathy. Moreover, the more angry individuals were about the vaccine, the less willing they were to get vaccinated. However, the more joy, hope, relief, and empathy they experienced, the more willing they were to get vaccinated. These emotions also mediated relations between vaccine confidence and hesitancy wherein for confidence, joy and relief were positive mediators whereas anger was a negative mediator and, for hesitancy, relief was a negative mediator whereas empathy was a positive mediator. These results have important implications for the effects that emotions have on processing persuasive information, particularly when the message focuses on getting life back to normal under pandemic circumstances. Drawing from the emotions literature (32), it may bethe case that processing of the persuasive messages was enhanced due to an increase in joy, hope, and relief across all three conditions. These results suggest that persuasive messages that focus on getting back to normal could persuade the largest number of individuals to get vaccinated, particularly those who are vaccine hesitant/resistant. Although vaccine campaigns have targeted vaccine safety and protection of oneself (self-interest) and others (altruistic), an additional focus on getting back to a normal life may bekey to achieving a high vaccine uptake. In the context of COVID-19 where, in Canada, many restrictions were put into place that limited individuals’ freedoms (particularly in the province of Quebec), a focus on regaining those freedoms via vaccination and “getting back to normal” may have been a powerful approach to social persuasion. In other contexts, this “normal” message may not have been effective if freedoms were not restricted. As such, the efficacy of this approach may not translate to other situations where freedoms are not threatened. Implications, limitations, and future directions Taken together, results from this study have broader vaccine education and promotion implications. Messages from trustworthy sources are important to incorporate into health promotion messaging, along with a highlight of the safety of the vaccine. Given the history of vaccine hesitancy (55), mandating vaccines is not a good choice to promote vaccine uptake. Rather, results from this study suggest that choice is critical as is a focus on freedoms rather than the removal of them. Education about the safety and efficacy of vaccines is also critical (55). But in the context of rapidly changing information about COVID-19 and vaccines, this element of vaccine safety and efficacy was nearly impossible, so freedom of choice may have been key. Results from this research also suggest that positive emotional appeals may prompt individuals to beless resistant to vaccines and foster confidence in their use. From an information processing perspective (35), it may bethe case that positive emotions foster a deeper processing of educational 19 Muis et al. 10.3389/fpubh.2024.1377973 Frontiers in Public Health 10 frontiersin.org information about vaccines. Future research is needed to evaluate precisely how emotions impact information processing, particularly for vaccine hesitant individuals. For example, a think-emote-aloud protocol [see (62)] may bean effective way to capture individuals’ emotions and cognitive and metacognitive processes to examine their interplay during reading of persuasive messages, particularly for socio-scientific issues like vaccine hesitancy. Future research is also needed that takes into consideration other factors that affect vaccine uptake like perceived susceptibility, threat or severity of illness, and the potential role of community engagement. Moreover, our study was conducted in Canada, which, culturally, is considered a more socialist country compared to others like the U.S. What was surprising to us was the finding that “protecting others” did not have the positive effect on willingness as it has in the past in the Canadian context [see (12)]. Future work is needed to disentangle why this may have been the case and whether other cultures that are more or less collectivist or socialist would respond in similar ways to “getting back to normal.” One limitation of this study is that wedid not include altruistic only or normal only message conditions to better determine what specific aspect of the messages were most effective in increasing individuals’ willingness to get vaccinated. A second limitation of this study is that wedid not measure actual vaccine uptake. Although vaccine intentions are a strong predictor of behavior (63), a more powerful evaluation of the effectiveness of our messages would have been to include a follow-up assessment as to whether individuals got vaccinated for COVID-19 or not. Future research should also consider interviewing individuals to better understand the effects of persuasive messages and why individuals were more willing (or not) to get vaccinated. A better understanding of the underlying mechanisms of persuasion will allow for improved persuasive messages that may more effectively combat vaccine hesitancy and resistance. Data availability statement The raw data supporting the conclusions of this article will bemade available by the authors, without undue reservation. Ethics statement The studies involving humans were approved by Research Ethics Review Board at McGill University. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Author contributions KM: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. PK: Conceptualization, Methodology, Validation, Visualization, Writing – review & editing. MK: Writing – review & editing. SW: Writing – review & editing. Funding The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. Support for this research was provided by a grant to KM from the Canada Research Chair’s Program (G239700). Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could beconstrued as a potential conflict of interest. Publisher’s note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. 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(2005) 20:761–74. doi: 10.1080/14768320500183368 22 Frontiers in Public Health 01 frontiersin.org Vaccine communication strategies among healthcare workers as a reflection of the Israeli Ministry of Health’s communication strategies before and after the COVID-19 pandemic RanaHijazi 1 *, AnatGesser-Edelsburg 1 and GustavoS.Mesch 2 1 The Health and Risk Communication Lab, School of Public Health, University of Haifa, Haifa, Israel, 2 Department of Sociology, University of Haifa, Haifa, Israel Background: Healthcare workers play a central role in communicating information to the public regarding vaccines. Most of the literature has focused on healthcare workers’ hesitancy and doubts about getting the flu vaccine themselves. However, few studies have dealt with how they perceive their role in communicating information regarding vaccines, especially following the COVID-19 pandemic. Objectives: (1) To identify the communication strategies used by the Israeli Ministry of Health regarding vaccines during epidemic crises (before and after the COVID-19 pandemic); (2) To identify the communication strategies used by healthcare workers regarding vaccines before and after the COVID-19 pandemic. Methods: A qualitative study based on in-depth interviews was conducted among healthcare workers and used a semi-structured protocol as a research tool. A total of 18 healthcare workers were sampled using purposeful and snowball sampling. Results: Despite healthcare workers’ perception that there has been a decrease in trust in the Israeli Ministry of Health among the public following the COVID-19 outbreak, they still rely on the Israeli Ministry of Health as their primary source of information and use the same communication strategies (such as fear appeals and correcting information) as of the Israeli Ministry of Health to communicate with the public, healthcare providers, and other relevant stakeholders. Conclusion: Healthcare workers have been shaped by the professional socialization processes within the health system, leading to a predominant reliance on established communication strategies and informational channels. This reliance underscores the importance of evolving these methods to better engage with the public. To address this, there is a compelling need to innovate and adopt new communication techniques that emphasize effective dialogue and transparent interactions. By doing so, healthcare professionals can ensure that their outreach is not only informative but also responsive to the diverse needs and preferences of the community. KEYWORDS vaccine hesitancy, healthcare workers, COVID-19 pandemic, health communication strategies, qualitative study, Israel, parents, public trust in the healthcare system OPEN ACCESS EDITED BY Carlos Alberto De Oliveira Magalhães Júnior, State University of Maringá, Brazil REVIEWED BY Willian Melo, State University of Paraná, Brazil Pier Luigi Sacco, University of Studies G. d'Annunzio Chieti and Pescara, Italy *CORRESPONDENCE Rana Hijazi [email protected] RECEIVED 27 January 2024 ACCEPTED 07 May 2024 PUBLISHED 23 May 2024 CITATION Hijazi R, Gesser-Edelsburg A and Mesch GS (2024) Vaccine communication strategies among healthcare workers as a reflection of the Israeli Ministry of Health’s communication strategies before and after the COVID-19 pandemic. Front. Public Health 12:1377393. doi: 10.3389/fpubh.2024.1377393 COPYRIGHT © 2024 Hijazi, Gesser-Edelsburg and Mesch. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. TYPE Original Research PUBLISHED 23 May 2024 DOI 10.3389/fpubh.2024.1377393 23 Hijazi et al. 10.3389/fpubh.2024.1377393 Frontiers in Public Health 02 frontiersin.org Introduction Health organizations during epidemics, and also when communicating information about children’s routine vaccines, have adopted several communication strategies to promote vaccination and encourage the public to get vaccinated (1, 2). This study seeks to shed light on some of the strategies employed by healthcare workers before and after the COVID-19 crisis. Myth-busting – differentiating between facts and myths – is commonly used by health organizations. According to this approach, every piece of information that comes from other sources besides the health organization itself is labeled as a “myth,” while information that originates from the health organization itself is labeled as “fact” (3). Several studies have noted the problematic use of this strategy, which was found to result in a backfire effect (4–6); the public refused to accept this information unless it was supported by scientific evidence (7–9). In addition, repeating the “myth” by the health organizations was found to make the information more familiar and more likely to betrue (6). Hence, studies conducted during the COVID-19 outbreak found that health organizations continue to use the same communication strategies of myth-busting and fear appeal strategies (2, 10). Health organizations also widely used the fear appeal strategy during previous disease outbreaks. A fear appeal strategy attempts to persuade the public to adopt a specific action (such as vaccination or compliance with instructions) by arousing fear. This strategy is based on emphasizing the potential danger and harm that might result if the public does not adopt the messages’ recommendations (11). A comprehensive meta-analysis of fear appeal literature indicates that this strategy is ineffective (12). Moreover, fear appeal has also been associated with negative effects and responses such as risk denial, biased information processing, lower levels of self-efficacy, less attention, and a higher level of discomfort after being exposed to fear appeal messages during a vaccine promotion campaign (13, 14). Previous studies emphasized the apparent use of a fear appeal strategy by the Israeli Ministry of Health during the COVID-19 vaccination campaign (2). The use of this strategy was characterized by the language and tone politicians used to deliver information in the media (15, 16). Health organizations have used these communication strategies and reached the public through the media, especially through channels such as social media in the last decade. However, the primary way of communicating with the public is still through healthcare workers, including nurses and physicians. Healthcare workers are considered the representatives of health organizations and as such play an essential role in public vaccination (17). This role includes communicating recommendations, providing information about vaccines, and vaccinating the public (18). Physicians and other healthcare providers are considered the most reliable source of information (19). Parents perceive healthcare workers as a primary and trustworthy source of information about vaccination and vaccines (20) and play a central role in maintaining public trust in vaccination (21). Healthcare workers’ recommendations were found to bestrong drivers of vaccine acceptance among the public. Therefore, they are in a position to empower parents to make an informed decision about vaccinating their children (19). Due to the essential role of healthcare workers in the vaccination process and as a trusted source of information for parents, as well as influencing the parents’ attitudes regarding vaccination, there is a need for a better understanding of how they communicate vaccination information. This is further supported by the fact that most of the studies in the literature on healthcare workers and vaccines have focused on vaccine hesitancy, vaccine acceptance, and vaccination intention among healthcare workers (22–24). However, few studies have dealt with how healthcare workers perceive their role in communicating information regarding vaccines to the public, especially following the COVID-19 pandemic. This study aims to (1) Identify the communication strategies used by the Israeli Ministry of Health regarding vaccines during epidemic crises (before and after the COVID-19 pandemic); (2) Identify the communication strategies used by healthcare workers regarding vaccines before and after the COVID-19 pandemic. Methods Research design and procedure This study is based on a qualitative constructivist research method (25), which enables the researchers to study the meaning of the experience as it is perceived by the research subjects. In this study, healthcare workers themselves are used as the instrument for data collection to identify the communication strategies employed by healthcare workers and health organizations (26). The study was approved by the Faculty of Social Welfare and Health Sciences Ethics Committee for research with human subjects at the University of Haifa (approval no. 421/17). The studies were conducted in accordance with the Israeli Medical Research Involving Human Subjects Law (1996) as the local legislation, and the requirements and guidelines set by the University of Haifa Ethics Committee. Written informed consent to participate in this study was provided by the participants. Sampling and data collection In the first stage, the researchers performed a purposeful criterion sampling of healthcare workers such as family physicians, pediatricians, and nurses who are involved in the vaccination process with the public, including giving vaccines and communicating information regarding vaccines to the public. In the second stage, the researchers proceeded to perform snowball sampling. The study’s sample included 18 healthcare workers – 9 pediatricians, 1 physician, and 8 nurses from the Mother and Child Health Clinics were interviewed (Table1). The duration of each interview was approximately half an hour. Research tools In-depth interviews were conducted based on a semi-structured protocol. In the first part, the questions referred to the period before the COVID-19 outbreak in Israel. The interviewees were asked questions about how they communicate the issue of vaccines to the parents, how the Israeli Ministry of Health communicates the issue of vaccines, how they deal with uncertainty, and how they correct misinformation regarding vaccines. In addition, the 24 Hijazi et al. 10.3389/fpubh.2024.1377393 Frontiers in Public Health 09 frontiersin.org It is important to note, though, that thematic saturation was achieved within the analysis. In addition, the sample consisted of specific categories of healthcare workers (pediatricians, a physician, and nurses), who primarily work at child health centers that belong to the Ministry of Health and health organizations. As such, it is possible that the attitudes and perceptions shared may not fully encompass the diversity of views among Israel’s broader healthcare community, which includes a more extensive array of professional roles and specializations. Therefore, future studies should include other healthcare workers besides the ones in the study sample. Further studies should also beconducted to evaluate the healthcare workers’ trust in the health authorities, due to a dearth of these studies in the literature. It is important to note that this study was partly conducted before the COVID-19 outbreak and resumed after the COVID-19 vaccination campaign. Therefore, it aimed to address the change in attitudes and perceptions among healthcare workers regarding the communication of the vaccine issue. Thus, follow-up studies on healthcare workers’ communication strategies should beconducted. Conclusion In summary, the study’s findings indicate that healthcare workers have undergone professional socialization by the health system. Despite healthcare workers’ perception that there has been a decrease in the public’s trust in the Ministry of Health following the COVID-19 outbreak, the workers, themselves, continue to adopt the same communication strategies as the health authorities. Therefore, to increase the public’s trust in both the healthcare system and in healthcare workers, multifaceted approaches and policies are recommended. Health organizations, authorities, and healthcare workers need to change their communication strategies to regain public trust. This includes transparently providing complete information, encouraging open dialogue to address public concerns and fears, and empowering healthcare workers to engage patients through dedicated discussion time and communication training. Health authorities and workers should also collaborate on unified messaging campaigns to enhance credibility, while tailoring outreach efforts to acknowledge the diversity of public perspectives across different demographic groups. It is important to note that while these recommendations are based on the findings from this study, the limited generalizability of the study should beconsidered. Data availability statement The raw data supporting the conclusions of this article will bemade available by the authors, without undue reservation. Ethics statement The studies involving humans were approved by the Faculty of Social Welfare and Health Sciences Ethics Committee for research with human subjects at the University of Haifa (approval no. 421/17). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Author contributions RH: Conceptualization, Data curation, Formal analysis, Investigation, Validation, Writing – original draft, Writing – review & editing. AG-E: Conceptualization, Formal analysis, Supervision, Validation, Writing – original draft, Writing – review & editing. GM: Supervision, Writing – review & editing. Funding The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article. Acknowledgments This study was part of RH PhD dissertation conducted at the School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, supervised by AG-E and GM. Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could beconstrued as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. 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(2020) 93:654–86. doi: 10.1111/joop.12310 33 Frontiers in Public Health 01 frontiersin.org Determinants of influenza non-vaccination among Canadian children: insights from a nationwide survey AbdallahAlami 1 *, SaillyDave 1, CarenUhlik 1, MarwaEbrahim 1, DanielKrewski 2 and JulieLaroche 1 1 Vaccine Coverage and Effectiveness Surveillance Division, Infectious Diseases and Vaccination Programs Branch, Public Health Agency of Canada, Ottawa, ON, Canada, 2 School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada Background: To identify determinants influencing Canadian parents’ decision not to vaccinate their children aged 6 months to 17 years against seasonal influenza. Methods: Data from the 2022 Childhood COVID-19 Immunization Coverage Survey, a national survey of approximately 10,500 Canadian parents/guardians and their children, was analyzed. The survey examined influenza vaccine coverage, parental perspectives on vaccines, reasons for hesitancy, and factors influencing immunization. Socio-demographic characteristics, including ethnicity, household income, working sector, educational attainment, and prevalence of chronic medical conditions among children were considered. Historical vaccine uptake and the impact of the COVID-19 pandemic on immunization decisions were also reviewed. Key determinants of non-vaccination in the 2021–2022 influenza season were analyzed using multivariable logistic regression, with a statistical significance level set at p-value <0·05. Results: 70% of children aged 6 months to 17 years did not receive the seasonal influenza vaccine. Key predictors for non-vaccination included: residing in rural settings (aOR 1·35, 95% CI 1·13–1·60), parental education attainment of less than high school (aOR 2·48, 95% CI 1·24–4·97), and the absence of chronic medical conditions in children (aOR 1.60, 95% CI 1.34-1.91)· Other strong predictors included lower household income; deterrence due to the COVID-19 pandemic; and parental hesitancy stemming from concerns about the vaccine’s safety, effectiveness, and by beliefs that their child was not at risk of contracting the influenza or severe consequences from the infection. Conclusion: This research underscores pivotal determinants of parental decisions not to vaccinate their children against seasonal influenza and sheds light on the impact of the COVID-19 pandemic. The results highlight the importance of addressing safety concerns and providing clear information to alleviate hesitancy. KEYWORDS influenza, survey, vaccine hesitancy, public health, immunization, COVID-19, Canada OPEN ACCESS EDITED BY Carlos Alberto De Oliveira Magalhães Júnior, State University of Maringá, Brazil REVIEWED BY Nuria Torner, University of Barcelona, Spain Fortino Solórzano-Santos, Federico Gómez Children's Hospital, Mexico *CORRESPONDENCE Abdallah Alami [email protected] RECEIVED 14 March 2024 ACCEPTED 16 May 2024 PUBLISHED 05 June 2024 CITATION Alami A, Dave S, Uhlik C, Ebrahim M, Krewski D and Laroche J (2024) Determinants of influenza non-vaccination among Canadian children: insights from a nationwide survey. Front. Public Health 12:1400782. doi: 10.3389/fpubh.2024.1400782 COPYRIGHT © 2024 Alami, Dave, Uhlik, Ebrahim, Krewski and Laroche. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. TYPE Original Research PUBLISHED 05 June 2024 DOI 10.3389/fpubh.2024.1400782 34 Alami et al. 10.3389/fpubh.2024.1400782 Frontiers in Public Health 02 frontiersin.org Introduction Childhood vaccination is fundamental in maintaining the health of both individuals and the broader community, especially when it comes to the seasonal influenza. This respiratory illness, though common, can lead to severe health complications, especially in young children and people over 65 years of age, as well as in those with underlying chronic health conditions (1, 2). Children are particularly vulnerable to the seasonal influenza, with data from Canada showing they are disproportionately affected (3). Complications from influenza in children can include pneumonia, dehydration, and worsening of long-term medical problems such as heart disease or asthma, sinus problems, and ear infections (4). In rare cases, influenza complications can lead to death (4). According to the Canadian Immunization Monitoring Program Active (IMPACT) surveillance network, between 2004 and 2005 and 2012–2013 (excluding the 2009–2010 pandemic season) pediatric seasonal influenza was confirmed in 15·5% to 58·3% of hospital admissions in children 16 years of age and younger (5, 6). In the wake of the COVID-19 pandemic, the 2022–2023 seasonal influenza season in Canada marked a significant shift, resembling pre-pandemic seasonal influenza activity but with notable impact on pediatric population (7). According to the National Influenza Annual Report, Canada, 2022– 2023, which draws on FluWatch data (a long-standing national surveillance system monitoring the spread of influenza and influenzalike illness in Canada), nearly half (45%; n = 6,194/13,729) of the reported influenza A detections occurred in the pediatric population (younger than 19 years) (7). Furthermore, when hospitalizations are broken down by type, the pediatric population accounted for 49% of hospitalizations associated with influenza B, compared to 22% for influenza A (7). Additionally, during this period, weekly pediatric influenza-associated hospital admissions persistently exceeded historical peak levels, with children aged 0–4 years being the most affected group, experiencing the highest cumulative hospitalization rate at 131 per 100,000 population (7). Given these findings, and to mitigate the potential complications of seasonal influenza infection in children, the National Advisory Committee on Immunization (NACI) continues to recommend that the seasonal influenza vaccine should beoffered annually to anyone 6 months of age and older who does not have a contraindication to the vaccine (5). Despite the availability of an effective vaccine, many parents are choosing not to vaccinate their children against the influenza (8). Gaining insights into the reasons behind these decisions is critical not only to boost vaccination rates, but also to ensure the broader community remains protected. With vaccine hesitancy frequently expressed during the recent COVID-19 pandemic, monitoring and understanding parental attitudes toward vaccination is critical to increasing seasonal influenza vaccination uptake. Parental perceptions can provide insight into expected vaccine uptake and can help shape public educational and awareness campaigns. This is particularly important given the high degree of uncertainty in estimates of seasonal influenza vaccine coverage in children. This study aims to explore factors associated with non-vaccination against the seasonal influenza in Canadian parents of children aged 6 months to 17 years old. The results of this study can provide valuable insights into parental attitudes and beliefs about influenza vaccination and inform the development of targeted interventions aimed at increasing seasonal influenza vaccination rates and protecting public health. Methods Data source This study utilizes data from the 2022 Childhood COVID-19 Immunization Coverage Survey (CCICS) (9), an annual survey first implemented by the Public Health Agency of Canada in 2022. Data collection for this survey was conducted over a period extending from April 20 to July 21, 2022. The survey constitutes a nationally representative dataset for Canadian parents or guardians with children in specific age groups (0–4, 5–11, and 12–17 years). CCICS encompasses all Canadian provinces and territories and ensures a balanced representation of males and females. As a surveillance tool, CCICS provides both national and provincial/territorial-level estimates of several key factors, including seasonal influenza vaccine coverage among eligible children; knowledge, attitudes, and beliefs (KAB) of respondents toward vaccinations; and barriers and facilitators to immunization. The survey also provides information about the impact of the COVID-19 pandemic on vaccination decisions, as well as vaccination history and uptake among children and their parents or guardians. Socio-demographic data including household income, working sector, education, and citizenship status in Canada are also collected in the survey. Study design This cross-sectional study employed a probability-based sampling strategy, where the CCICS aimed for a sample size of 10,500 Canadian parents or guardians 18 years of age or older. To achieve a nationally representative sample, respondents were recruited from a general population sample by random digit dialing (RDD) (10), across all provinces and territories. The sampling framework allows for extrapolation to the broader Canadian population. To strengthen statistical power and ensure national representativeness, quotas were set for key sub-populations.1 Survey sampling weights were applied to mirror the demographic composition of the Canadian population of children, based on child’s sex, child’s age group and province or territory of residence (based on the most recent data from the 2021 Statistics Canada census). Bootstraps were generated and applied to estimate variance. Overall, 100·3% of the target sample size was successfully achieved, ensuring that the study had adequate power. Data collection Data was captured using a multimodal approach, administered either online or through computer assisted telephone interviewing (CATI). CATI was specifically done in hard-to-reach populations to increase response rates (targeting parents in Atlantic and Northern provinces/territories who are often more difficult to reach online). This flexible approach facilitated comprehensive data collection across diverse demographic groups. 1 Key sub-populations for quotas included: parents with children aged 0–4, 5–11, and 12–17 years; parents from all provinces and territories; and a gender balance among children (50% males, 50% females). 35 Alami et al. 10.3389/fpubh.2024.1400782 Frontiers in Public Health 03 frontiersin.org Inclusion and exclusion criteria In alignment with Health Canada’s seasonal influenza vaccination authorization starting at 6 months of age, this analysis purposely excludes data on children younger than 6 months. Results are therefore based on survey responses from parents or guardians of children aged 6 months to 17 years across all Canadian provinces and territories. Missing data were not expected to pose a significant issue. A threshold for data removal was established: any variable exhibiting more than 20% missing data was excluded from the regression analysis. To assess the randomness of missing values in the dataset, we generated graphical summaries visualizing the patterns of missingness across variables: this visualization was performed for variables with more than 5% of missing data, allowing for an evaluation of whether the missing values demonstrated any discernable trends or patterns (Supplementary material, Supplementary Figure S1). Statistical and data analysis R Statistical Software (version 4·1·3; R Foundation for Statistical Computing, Vienna, Austria) was used for data analysis, including data filtering, analysis and wrangling, and both descriptive and inferential statistical analyses (11). Initial data exploration involved summarizing categorical dependent and independent variables using descriptive statistics. Unweighted and weighted frequencies and proportions were calculated, stratified by seasonal influenza vaccination status. Likert plots were used to summarize parental opinions on key KAB questions about vaccines: this graphical representation displayed the range of parental responses, from ‘Strongly Agree’ to ‘Strongly Disagree,’ for various belief statements about vaccine safety and effectiveness. In line with our research objectives, weanalyzed and incorporated parental hesitancy, along with its underlying reasons, to better understand determinants of children’s non-vaccination against seasonal influenza. In the survey, parents were asked about their hesitancy to vaccinate their child against the influenza during the 2021–2022 season. Those who indicated hesitancy were prompted to select their specific reason(s). Given that respondents could choose multiple reasons, wecategorized these into three broad categories for analytical purposes: 1. concerns about vaccine effectiveness, safety, and perceived risk which encompassed doubts about the influenza vaccine’s efficacy, children’s susceptibility to flu, potential vaccine side effects, concerns regarding combined influenza and COVID vaccinations, and past adverse vaccine events; 2. barriers related to access and information availability, including hesitancy due to challenges in discussing the influenza vaccine with healthcare experts, sourcing trustworthy information, and unfavorable encounters with medical practitioners; and 3. personal beliefs and other influences, such as religious or philosophical stances and fears of racism or discrimination. From these categories, wedeveloped a five-level classification system for analysis: • “Not Hesitant,” • “Hesitant: Effectiveness/Safety/Perceived Risk” (derived from the first category), • “Hesitant: Access/Information” (from the second category), • “Hesitant: Personal/Other Influences” (reflecting the third category), • “Hesitant: Multiple Reasons” (for those indicating reasons across multiple categories). This structured approach not only enriched our understanding of the multifaceted influences on vaccination hesitancy, but also was instrumental for our regression models. The five-level classification system facilitated a comprehensive exploration of the relationship between influenza vaccine hesitancy, vaccine uptake, and the specific parental reasons behind hesitancy. A multivariable logistic regression model was employed to explore factors associated with non-vaccination of children aged 6 months to 17 years against the seasonal influenza. To account for the complexities of our survey design, weestimated standard errors, coefficients of variation, and confidence intervals using the bootstrap technique (12). As a starting point, univariate logistic regression analyses were fit to the survey data for each predictor to derive unadjusted odds ratios (ORs), with confidence interval (CI) set at 95%. Variables not achieving statistical significance at this stage were not immediately excluded; rather, as their effect could become apparent in a multivariable context after controlling for other variables, they were earmarked for potential removal in later stages. To address multicollinearity among categorical predictors, weemployed Cramer’s V, guided by thresholds established by Lee etal. (13). Predictors exceeding a Cramer’s V value of 0·4 were flagged for removal to mitigate the effects of a possible multicollinearity. Weadopted a ‘best fit’ strategy for construction multivariable models. This entailed initially incorporating all relevant predictors, including those that showed statistically insignificant effects in the univariate analysis but were deemed practically significant. A stepwise backward elimination process was then conducted, guided by the Akaike Information Criterion (AIC), p-values, and adjustments for multiple comparisons. The final model was selected based on a combination of statistical significance, minimized AIC values and domain expertise. Adjusted odds ratios (aOR) were used to evaluate relationships between predictors and the outcome of non-vaccination among children. A likelihood ratio test was used to validate the goodness of fit of the final model (14). An odds ratio plot was generated using ggplot2 and Finalfit packages in R (15) to visualize predictors and their respective aORs in the final model: this plot included 95% CI on the aORs to gage the impact of each variable on the likelihood of non-vaccination in children. Results Sociodemographic characteristics of the survey population A total of 10,536 individuals participated in the survey, achieving an overall response rate of 26·1%. Of these, 10,236 respondents were included in the analysis, as responses from parents or guardians of children under 6 months of age were not included. Table 1 presents the sociodemographic characteristics of the survey population, stratified by vaccination status. This table provides a comprehensive overview of the sample population across different variables, including province/territory, age of child and responding parent, sex, urban/rural setting, ethnicity, and household income. 36 Alami et al. 10.3389/fpubh.2024.1400782 Frontiers in Public Health 04 frontiersin.org TABLE1 Sociodemographic characteristics of survey respondents, stratified by child seasonal influenza vaccination status. Overall Vaccinated children Unvaccinated children Characteristic N (%)1N (%)1N (%)1 Sample size 10,236 (100·0) 3,230 (30·0) 7,006 (70·0) Province/Territory Alberta (AB) 1,240 (13·5) 463 (17·3) 777 (11·8) British Columbia (BC) 1,342 (12·1) 444 (13·6) 898 (11·5) Manitoba (MB) 399 (4·3) 180 (6·6) 219 (3·3) New Brunswick (NB) 382 (1·9) 139 (2·2) 243 (1·7) Newfoundland and Labrador (NL) 389 (1·2) 168 (1·7) 221 (0·9) Nova Scotia (NS) 408 (2·3) 159 (3·0) 249 (2·0) Ontario (ON) 3,019 (37·9) 932 (39·3) 2,087 (37·4) Prince Edward Island (PE) 386 (0·4) 165 (0·6) 221 (0·3) Quebec (QC) 1,945 (22·2) 251 (9·5) 1,694 (27·6) Saskatchewan (SK) 404 (3·8) 175 (5·5) 229 (3·1) Territories 322 (0·4) 154 (0·7) 168 (0·3) Child age 6 months – 4 years 2,551 (25·1) 1,047 (33·4) 1,504 (21·5) 5–11 years 3,724 (40·4) 1,166 (39·1) 2,558 (40·9) 12–17 years 3,961 (34·6) 1,017 (27·6) 2,944 (37·6) Age of responding parent 18–29 201 (1·7) 50 (0·9) 151 (2·0) 30–39 2,968 (30·0) 1,039 (33·0) 1,929 (28·7) 40–49 4,932 (49·2) 1,511 (47·9) 3,421 (49·8) 50+ 2,025 (19·1) 612 (18·1) 1,413 (19·6) Child sex at birth Male 5,306 (51·0) 1,656 (50·2) 3,650 (51·3) Female 4,930 (49·0) 1,574 (49·8) 3,356 (48·7) Sex of responding parent Male 3,990 (39·2) 1,209 (37·5) 2,781 (39·9) Female 6,191 (60·8) 2,015 (62·5) 4,176 (60·1) Urban/rural setting Urban 8,415 (86·1) 2,743 (89·7) 5,672 (84·5) Rural 1,737 (13·9) 475 (10·3) 1,262 (15·5) Ethnicity of responding parent Black 267 (2·9) 38 (1·3) 229 (3·6) East/Southeast Asian 457 (4·4) 176 (5·5) 281 (3·9) South Asian descent 304 (3·5) 94 (3·4) 210 (3·5) Latin American 153 (1·7) 44 (1·4) 109 (1·8) Middle Eastern and North African 222 (2·5) 54 (1·9) 168 (2·7) Indigenous 158 (0·9) 52 (0·9) 106 (0·9) White European descent 7,825 (79·1) 2,572 (80·8) 5,253 (78·3) Other/Mixed parent ethnicity 476 (5·1) 138 (4·8) 338 (5·3) Education of responding parent Less than high school 134 (1·1) 25 (0·4) 109 (1·4) High school or equivalent 808 (7·3) 212 (6·1) 596 (7·9) Postsecondary below Bachelor’s 3,247 (31·5) 766 (22·1) 2,481 (35·6) Bachelor’s or above 5,926 (60·0) 2,209 (71·3) 3,717 (55·1) (Continued) 37 Alami et al. 10.3389/fpubh.2024.1400782 Frontiers in Public Health 05 frontiersin.org Thirty percent (30·0%, N = 3,230) of children younger than 18 years were vaccinated against seasonal influenza. A majority of the responding parents/guardians were female (60·8%) and of White European descent (79·1%). Nearly two thirds of the parents (60·0%) had a bachelor’s degree or higher, with 39·4% reporting being employed in high-risk sectors (including health care or laboratory workers, those working in child care or schools, those exposed to animals or their materials, and emergency services workers). Children ranged in age from 6 months to 4 years (25·1%), 5 to 11 years (40·4%), and 12 and 17 years (34·6%). A small minority of children had chronic medical conditions (12·4%) and disabilities (6·5%). Pre-Pandemic and current seasonal influenza vaccination patterns among parents and children Prior to the COVID-19 pandemic, 42·7% of parents indicated that they typically received an seasonal influenza vaccine either every influenza season or most seasons. However, for the 2021–2022 influenza season, two-thirds (66·9%) of parents opted out of receiving the vaccine, while only one-third (33·1%) reported getting vaccinated (Table 2). When asked about their child’s seasonal influenza vaccination status prior to the COVID-19 pandemic, 38·4% of parents indicated vaccinating their child every or most influenza seasons, 18·5% reported having their children vaccinated sometimes, and 43·1% reported never vaccinating their child against the flu. A great majority of parents (93·3%) reported that their child had received all recommended routine vaccinations, with a further 4·2% receiving partial vaccinations, and 2·4% remaining unvaccinated. Concerning the likelihood of having their child vaccinated against seasonal influenza in the upcoming season, approximately half (50·3%) of parents signaled strong intent (either ‘definitely will’ or ‘probably will’) to have their children vaccinated; 22·9% of parents expressed a moderate likelihood of avoiding vaccination, saying they ‘probably will not’, while 18·9% expressed strong views against vaccination, responding with ‘definitely will not’. The most common motivation for parents vaccinating their child was self and household protection from seasonal influenza (85·0%), followed by desire to prevent the spread of seasonal influenza in the TABLE1 (Continued) Overall Vaccinated children Unvaccinated children Status of residency in Canada Canadian by birth 8,111 (78·5) 2,684 (82·1) 5,427 (76·9) Canadian by naturalization 1,578 (17·0) 405 (14·1) 1,173 (18·3) Permanent resident/landed immigrant 447 (4·1) 122 (3·5) 325 (4·4) Refugee claimant/Asylum seekers 9 (0·1) 4 (0·1) 5 (0·1) Temporary resident 36 (0·2) 9 (0·2) 27 (0·3) Working sector of responding parent High-risk sector23,970 (39·4) 1,326 (40·4) 2,644 (38·9) Not high-risk sector 5,969 (60·6) 1,859 (59·6) 4,110 (61·1) Total household income ($) Under 40,000 650 (6·7) 136 (4·5) 514 (7·6) 40,000-59,999 721 (7·3) 153 (4·5) 568 (8·5) 60,000-79,999 870 (8·9) 222 (6·6) 648 (9·9) 80,000-99,999 1,152 (11·9) 324 (10·1) 828 (12·7) 100,000-149,999 2,502 (27·0) 776 (25·5) 1,726 (27·7) 150,000 and above 3,522 (38·2) 1,414 (48·8) 2,108 (33·5) Prevalence of chronic conditions among children With chronic condition31,285 (12·4) 473 (14·7) 812 (11·4) Without chronic condition 8,835 (87·6) 2,729 (85·3) 6,106 (88·6) Prevalence of disabilities among children With disability4675 (6·5) 197 (6·0) 478 (6·7) Without disability 9,477 (93·5) 3,011 (94·0) 6,466 (93·3) 1Percent weighted by: region, child’s age group, and child’s sex at birth. 2High-Risk Working Sector: This category includes individuals currently employed or volunteering in sectors with elevated exposure risks. These sectors encompass healthcare, laboratory services, childcare, educational institutions, occupations with animal exposure, emergency services, and other critical roles such as staff in correctional facilities, crew on ships or aircraft, military personnel, humanitarian relief workers, and providers of essential community services. 3Chronic Medical Condition: This refers to health conditions as outlined in the Canadian Immunization Guide and include sickle cell anemia or thalassemia major, neurological or neurodevelopmental disorders, asthma and other chronic respiratory diseases, chronic conditions affecting the liver, heart, or kidneys, diabetes, obesity, Down Syndrome, immune suppression (due to chemotherapy, radiotherapy, steroid use, HIV, organ transplants), cancer, and other significant medical conditions. 4Disability: This is defined as a person who has a long-term or recurring impairment (such as vision, hearing, mobility, flexibility, dexterity, pain, learning, developmental, memory or mental health-related) which limits their daily activities inside or outside the home (such as at school, work, or in the community in general). 38 Alami et al. 10.3389/fpubh.2024.1400782 Frontiers in Public Health 06 frontiersin.org community (49·0%), and the fact that the child receives the vaccine annually (48·0%).2 Parental attitudes, influences, and barriers to seasonal influenza vaccination A substantial majority of parents expressed favorable opinions regarding general vaccine safety and effectiveness. Specifically, 91·4% 2 As participants could select multiple options, percentages do not add to 100%. of parents either strongly or somewhat agreed that vaccines are generally safe, and 92·2% concurred on their effectiveness. Confidence levels in seasonal influenza vaccines varied somewhat: 85·4% of parents believed the influenza vaccine to besafe, and 71·4% attested to its effectiveness. A Likert plot displaying the range of responses on the various belief statements is provided in Figure1, illustrating the distribution of opinions among survey respondents. Approximately 24% of parents expressed hesitancy in vaccinating their child against seasonal influenza. The primary reason underlying this hesitancy was the belief that their child was not at risk of contracting influenza or developing severe symptoms, a view held by nearly half (47·2%) of these hesitant parents. Additional reservations were grounded in concerns about the influenza vaccine’s effectiveness (35%) and apprehensions regarding its safety or potential side effects (29·4%). These TABLE2 Parental and child seasonal influenza vaccination history, future intentions, and reasons for vaccination. Vaccination history and reasons for vaccination N (%)1 Responding parent frequency of receiving an influenza vaccine prior to COVID-19 Every influenza (flu) season 2,475 (23·2) Most influenza (flu) seasons 2,006 (19·5) Some influenza (flu) seasons (including once only) 2,818 (27·8) Never 2,894 (29·5) Responding parent influenza vaccination during the 2021–2022 influenza season Yes, vaccinated 3,928 (37·1) No, did not get the vaccine 6,263 (62·9) Uptake of recommended routine child vaccination Complete 8,786 (93·3) Partial 384 (4·2) None 219 (2·4) Child frequency of receiving a influenza vaccine prior to the COVID-19 pandemic Every influenza (flu) season 2,330 (24·3) Most influenza (flu) seasons 1,354 (14·1) Some influenza (flu) seasons (including once only) 1,783 (18·5) Never 3,831 (43·1) How likely is it that youwill get your child vaccinated against the influenza (flu) in the next influenza (flu) season? Definitely will 2,871 (26·7) Probably will 2,455 (23·6) Probably will not 2,264 (22·9) Definitely will not 1,836 (18·9) Do not know 780 (7·9) Reasons for child to receive a influenza (flu) vaccine To protect themselves and/or household members from the influenza (flu) 2,688 (84·5) Based on public health recommendations 1,507 (46·1) To prevent the spread of the flu in my community 1,594 (49·2) The influenza (flu) vaccine was recommended by a health care professional 928 (27·7) The influenza (flu) vaccine is available and free 1,343 (40·5) Increased concerns about flu because of the COVID-19 pandemic 914 (27·9) My child receives it every year 1,578 (48·9) Other 49 (1·6) 1Percent weighted by: region, child’s age group, and child’s sex at birth. 2Multiple response options could be selected by respondents. 39 Alami et al. 10.3389/fpubh.2024.1400782 Frontiers in Public Health 07 frontiersin.org specific reasons for hesitancy are further detailed in Table3. While the COVID-19 pandemic might have impacted seasonal influenza vaccination decisions for the 2021–2022 season, a notable majority (79·7%) of parents reported that the pandemic did not influence their choice. While the pandemic served as a motivator for 10·6% of parents, nearly an identical percentage found it to bea deterrent for vaccinating their child against the influenza. When examining the barriers that might have prevented parents from vaccinating children against seasonal influenza, the vast majority (81%) reported no obstacles to vaccination. Among the remaining parents who did face challenges, the barriers were diverse. Difficulty in securing time off from work or school was the most common obstacle, cited by 34% of these parents, followed by their child’s fear of needles (24%). Financial concerns were relatively rare, with only 3% citing the cost of the vaccine as a barrier. Other obstacles included limited access to transportation in remote areas (2%), language barriers (0·5%), and concerns about racism or discrimination (0·9%)·. Determinants of non-vaccination As detailed in Table4, the multivariable logistic regression models incorporated variables that were identified as predictors for non-vaccination against seasonal influenza in children. Independent predictors of non-vaccination included the child being in the older age group (12–17 years) compared to younger children (less than 12 years of age), residence in rural locales rather than urban settings (aOR: 1·35, 95% CI: 1·13–1·60, p < 0·001), and parental educational attainment below the level of a Bachelor’s degree compared to those with a Bachelor’s degree or above. Ethnicity of the parent was also found to bea predictor of non-vaccination, but its impact was not uniform across all groups, with children of Black parents significantly more likely to benon-vaccinated compared to children of White European descent (aOR: 2·91, 95% CI: 1·82, 4·67, p < 0·001). Children in lower household income tiers were associated with a significantly higher odds of non-vaccination compared to the highest income bracket (>$150,000): under $40,000 (aOR: 1·80, 95% CI: 1·35–2·41, p < 0·001) and $40,000–$59,999 (aOR: 2·07, 95% CI: 1·58–2·72, p < 0·001). Additionally, parents who perceived the COVID-19 pandemic as a deterrent to seasonal influenza vaccination were considerably more likely to refrain from vaccinating their child (aOR: 9·59, 95% CI: 6·04, 15·23, p < 0·001). Reasons given by respondents for their reluctance to vaccinate their children were strong predictors of non-vaccination. For example, parental hesitancy due to concerns about seasonal influenza vaccine effectiveness, safety, and perceived risk of infection were associated with a significant high odds of non-vaccination compared to non-hesitant parents (aOR: 18·78, 95% CI: 13·03, 27·08, p < 0·001). Figure2 provides a visual representation of the multivariable logistic regression model’s findings, which display the aORs and their 95% confidence intervals for each predictor of seasonal influenza non-vaccine. Discussion Using data from a nationally representative sample of Canadian parents/guardians with children under 18 years of age, this study explores factors influencing parental decisions to vaccinate children against seasonal influenza. Notably, during the 2021–2022 influenza FIGURE1 Parental attitudes toward vaccine safety and effectiveness: Likert plot distribution of responses on vaccine belief statements1. 1Percentages less than 5% are not numerically displayed for clarity. 40 Frontiers in Public Health 01 frontiersin.org Spatiotemporal analysis of HPV vaccination and associated neighborhood-level disparities in Texas—an ecological study RyanRamphul 1,2*†, AbigailS.Zamorano 3†, SaswatiUpadhyay 2,4, ManaliDesai 1 and CiciBauer 2,5,6 1 Department of Epidemiology, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, United States, 2 The Joint Collaborative on Geospatial Analysis and Health, A Collaboration of The University of Texas Health Science Center at Houston School of Public Health and The University of Texas MD Anderson Cancer Center, Houston, TX, United States, 3 Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, The University of Texas Health Sciences Center at Houston, McGovern Medical School, Houston, TX, United States, 4 Department of Environmental and Occupational Sciences, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, United States, 5 Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, United States, 6 Center for Spatial-Temporal Modeling for Applications in Population Sciences, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, United States Background: HPV is responsible for most cervical, oropharyngeal, anal, vaginal, and vulvar cancers. The HPV vaccine has decreased cervical cancer incidence, but only 49% of Texas adolescents have initiated the vaccine. Texas shows great variation in HPV vaccination rates. Weused geospatial analysis to identify areas with high and low vaccination rates and explored differences in neighborhood characteristics. Methods: Using Anselin’s Local Moran’s Istatistic, weconducted an ecological analysis of hot and cold spots of adolescent HPV vaccination coverage in Texas from 2017 to 2021. Next, weutilized a Mann–Whitney U test to compare neighborhood characteristics of vaccination coverage in hot spots versus cold spots, leveraging data from the Child Opportunity Index (COI) and American Community Survey. Results: In Texas, there are 64 persistent vaccination coverage hotspots and 55 persistent vaccination coverage cold spots. The persistent vaccination coverage hot spots are characterized by ZIP codes with lower COI scores, higher percentages of Hispanic residents, higher poverty rates, and smaller populations per square mile compared to vaccine coverage cold spots. Wefound a more pronounced spatial clustering pattern for male adolescent vaccine coverage than wedid for female adolescent vaccine coverage. Conclusion: In Texas, HPV vaccination coverage rates differ depending on the community’s income level, with lower-income areas achieving higher success rates. Notably, there are also gender-based discrepancies in vaccination coverage rates, particularly among male adolescents. This knowledge can aid advocates in customizing their outreach initiatives to address these disparities. KEYWORDS spatial analysis, HPV vaccination, vaccination disparities, cancer prevention, minority health, HPV, geospatial analysis, health care disparities OPEN ACCESS EDITED BY Carlos Alberto De Oliveira Magalhães Júnior, State University of Maringá, Brazil REVIEWED BY Gabriela Bustamante, Universidad San Francisco de Quito, Ecuador Nobila Jean Marc Ouedraogo, German Cancer Research Center (DKFZ), Germany *CORRESPONDENCE Ryan Ramphul [email protected] †These authors have contributed equally to this work and share first authorship RECEIVED 16 April 2024 ACCEPTED 06 June 2024 PUBLISHED 25 June 2024 CITATION Ramphul R, Zamorano AS, Upadhyay S, Desai M and Bauer C (2024) Spatiotemporal analysis of HPV vaccination and associated neighborhood-level disparities in Texas—an ecological study. Front. Public Health 12:1418526. doi: 10.3389/fpubh.2024.1418526 COPYRIGHT © 2024 Ramphul, Zamorano, Upadhyay, Desai and Bauer. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. TYPE Original Research PUBLISHED 25 June 2024 DOI 10.3389/fpubh.2024.1418526 47 Ramphul et al. 10.3389/fpubh.2024.1418526 Frontiers in Public Health 02 frontiersin.org Introduction Human papillomavirus (HPV) accounts for over 99% of cervical cancers and most oropharyngeal, anal, vaginal, and vulvar cancer (1, 2). More than 90% of HPV-associated cancers are preventable through HPV vaccination (3), which is recommended as a routine vaccination for children as early as age 9, with catch-up recommended up to age 26 for those not previously vaccinated and up to age 45 using shared clinical decision-making (4). Since the introduction of the HPV vaccine in 2006, there has already been a significant decline in nationwide cervical cancer incidence, especially in the 15–20-year age group, suggesting the positive impact of vaccination (5). However, the UnitedStates falls well behind its Healthy People 2020 target of 80% vaccinated adolescents, with only 54.5% completing the series (6, 7). As of 2017, only 49% of adolescents in Texas had initiated the HPV vaccine series, and the state ranks 47 out of 50in vaccination rates nationwide (8). Vaccination rates across the state are not geographically uniform, with some rural counties outperforming the major cities and the rest of the states (8, 9). While previous studies have demonstrated this regional variation, they have been limited to analyses of large state regions, which makes further analysis of associated sociodemographic factors incomplete. Geospatial analyses of HPV vaccination have been crucial to identify disparities and target areas for intervention. A systematic review of area-level variation in HPV vaccination uptake revealed significant differences influenced by socioeconomic factors, healthcare access, and educational attainment (10). For example, regions with higher poverty rates and lower access to healthcare services often exhibit lower vaccination rates. Conversely, areas with robust public health infrastructures and targeted education campaigns tend to achieve higher vaccination coverage. These findings emphasize the need for localized public health strategies considering these sociodemographic factors. By understanding the specific characteristics and barriers in different regions, public health initiatives can bebetter tailored to improve HPV vaccination rates effectively (10, 11). Such detailed geospatial and sociodemographic analyses can help bridge the gaps in HPV vaccination coverage, ensuring more uniform protection against HPV-associated cancers across diverse communities. Significant barriers to HPV vaccination exist, including lack of knowledge of the vaccine or the associated cancers, lack of access to immunization (involving geographic, financial, and public policy factors), lack of provider recommendation, and parental hesitations about accepting the vaccine for children/adolescents due to the association with a sexually transmitted infection (12). Weaim to geospatially model areas of Texas with persistently high or low levels of HPV vaccination coverage to better understand the associated arealevel characteristics and identify areas where increased vaccination efforts may bepursued. Methods Study population Data were obtained through the Texas Department of State Health Services Immunization Information System (ImmTrac2) Registry (13) on the percentage of registrants aged 9+ who received at least one dose of the HPV vaccine, categorized by ZIP code, for each year from 2017 to 2021. It also provided separate percentage estimates of male and female registrants aged 9+ who received at least one dose by ZIP for each year from 2017–2021. ImmTrac2 is a state-wide opt-in vaccine registry and includes information provided by healthcare providers, pharmacies, public health clinics, Medicaid claims administrators, and the Texas Department of State Health Services Vital Statistics Unit. While it contains information for both children and adults, most children are entered into the system at birth, while adults over 18 must consent to participate or continue participation. Additionally, vaccinations given to children must bereported by law (13). As a result, the ImmTrac2 registry is predominantly valuable as a database for vaccinations of childhood and adolescence. ImmTrac2 opt-in immunization registry requires parental consent to store children’s vaccination records. While Texas law mandates healthcare providers to report all immunizations given to children under 18 to ImmTrac2, including these records in the registry relies on obtaining parental or guardian consent. If consent is provided, the vaccination information is stored; otherwise, it is not, although the provider still meets the legal reporting requirement. The exact percentage of childhood vaccinations reported to ImmTrac2 varies based on consent rates, but mandatory reporting ensures a high overall reporting rate despite the lack of precise figures (13). In 2020, 80% of Texas children under 6 years old had at least two immunizations recorded in ImmTrac2 (14), indicating ImmTrac2’s robust coverage of pediatric populations. Data in this study was publicly available and received an exemption from Institutional Review Board (IRB) approval. Mapping and statistical analysis We utilized Anselin’s Local Moran’s Istatistic, pioneered by Luc Anselin in the “Local Indicators of Spatial Association—LISA,” to identify statistically significant clusters of ZIP codes with high/low estimated rates of HPV vaccination coverage each year from 2017 to 2021 (15). Using the Environmental Science Research Institute’s ArcGIS Pro Version 2.2.0 software, weran the Cluster and Outlier Analysis Tool, which implements the Local Moran’s Istatistic by first determining a “neighborhood” around each ZIP code in the dataset (16). While several strategies exist to determine the “neighborhood” around each ZIP code, weused the Queen Contiguity Method. In this method, all ZIP codes that touch a ZIP code are considered its “neighborhood” and are included in its computations (17). The Queen Contiguity Method has been successfully used in several studies to identify health outcomes and service clusters (17). After determining the neighborhoods around each ZIP code, the Cluster and Outlier Analysis Tool calculates a Local Moran’s Iscore for each ZIP code, where a positive value for “I” indicates that a ZIP code has a neighboring ZIP code with similarly high or low vaccination rates compared to the rest of the study area (16). These ZIP codes are part of clusters. After calculating a Local Moran’s Ifor each ZIP code in the data set, statistical significance is tested by running a Monte Carlo simulation. The values in the “neighborhoods” around each ZIP in the study area are randomly rearranged 9,999 times. A Local Moran’s Iscore is calculated each time, creating a random reference distribution of Local Moran’s Ito compare with the observed Local Moran’s I. A pseudo-p-value is then calculated by determining the proportion of Local Moran’s Istatistics generated 48 Ramphul et al. 10.3389/fpubh.2024.1418526 Frontiers in Public Health 03 frontiersin.org from random permutations that display more clustering than the original data. If the proportion is less than 0.05, the ZIP code is demarcated as a statistically significant vaccination coverage hot or cold spot (16). Persistent vaccination coverage in hot and cold spots were defined as ZIP codes that consistently exhibited statistically significant high or low vaccination coverage rates over five consecutive years, respectively. Finally, weutilized a Mann–Whitney U test to explore statistical differences in neighborhood characteristics between ZIP codes that were persistent vaccination coverage hot or cold spots for all registrants aged 9+ and then by male and female registrants. Median percentages of neighborhood characteristics (e.g., % Black, % below the federal poverty level, etc.) were chosen as the measure of the center instead of the mean because it is less affected by extreme values and skewed distributions. This provides a more accurate representation of the central tendency in our dataset, where variables like income and population density exhibit significant skewness. Statistical analyses were performed in SPSS version 28.01.1. Neighborhood evaluation metrics The Child Opportunity Index (COI) and the U.S. Census Bureau’s American Community Survey (ACS) were used to describe neighborhood characteristics (18, 19). The COI is a validated composite index to measure neighborhood resources and conditions. It consists of 29 social determinants of health (SDOH) indicators of neighborhood-based opportunities, including high-quality schools, green space, healthy food, toxin-free environments, and socioeconomic resources (18). COI indicators are assigned individual z-scores and summed to an overall z-score using indicator-specific weights that signify how strongly each indicator predicts children’s health and economic outcomes. Weused the most recent version of this data, which was from 2015. The COI indicators are divided into three subdomains: Education, Health and Environment, and Social and Economic. ZIP codes are scored as a very low opportunity, low opportunity, moderate opportunity, high opportunity, or very high opportunity within each domain (18). The ACS is the U.S. Census Bureau’s largest household survey and provides ZIP code level estimates of poverty levels, racial/ethnic diversity, insurance coverage, and population density (19). Weused the most recently published data (2016–2020), which gives an average estimate of the characteristics over the 60-month period. Finally, wecondensed ZIP code level Rural–Urban Commuting Area (RUCA) codes (20) into four categories (urban-focused, large rural city, small rural town, and isolated small rural town) as discussed by the Rural Health Research Center. Results The average percent of registrants (aged 9+) by ZIP code in Texas’s ImmTrac2 database who received at least one dose of the HPV vaccine remained relatively similar from 2017 to 2021, though trended slightly downward over the 5 years (Figure1). The average percentage ranged between 21 and 23%. Average vaccination rates by ZIP over this fiveyear period were higher for female adolescents than male adolescents, which aligns with trend data from the CDC’s National Immunization Surveys (11). Among the 1,800+ ZIP codes in Texas, weidentified 64 ZIP codes that were statistically significant hot spots of HPV vaccination coverage 5 years in a row and 55 ZIP codes that were cold spots of vaccination coverage 5 years in a row. As illustrated in Figures2, 3, the persistent vaccination coverage hot spots were primarily near the southern Gulf coast, the northwestern portion of the state, and close to El Paso. Cold spots were primarily located in the central portion of the state, the panhandle, and in parts of major urban areas like Houston and Dallas. However, on closer inspection of the major cities of Dallas and Houston, there are significant differences in these densely populated areas, with the cold spots in the urban and suburban wealthier areas and the hot spots in southeast Dallas and northeast Houston, which are typically lower income. The remainder of the ZIP codes in the state were not part of statistically significant clusters 5 years in a row or were outliers. When evaluating differences in HPV vaccination by reported gender, wefound 55 hot spot ZIP codes and 38 cold spot ZIP codes among male adolescents alone. These were in areas similar to overall hot/cold spots. However, among female adolescents alone, weidentified just 11 hot spot ZIP codes of HPV vaccination and 13 cold spot ZIP codes. These were also located in areas like overall hot/ cold spots (figures by gender not shown). Demographic analysis of persistent hot spot and cold spot ZIPs We found that persistent hot spot ZIP codes of HPV vaccination coverage had significantly lower overall COI scores, indicating lower opportunity areas than persistent cold spot ZIP codes (overall median score 2 vs. 4, p < 0.001, Table1). As seen in Figure2, Temporal changes in both vaccination hot spots and cold spots were identified. Over time, hot spots on the bottom part of the southern Gulf Coast expanded, whereas the northwestern portion has decreased. Cold spots, especially in the panhandle, expanded over time. Overall, spatial patterns were quite similar. This difference persisted in each subdomain (Education, Health, Environment, and Social and Economic) and when each was broken out by gender (Table1). As shown in Table2, using American Community Survey (ACS) data, persistent hot spot ZIPs had a higher median percentage of the population below the federal poverty level (17.40% vs. 7.14%, p < 0.001). Persistent hot spots also had higher rates of resident children who are either uninsured (2.87% vs. 1.92%, p < 0.001) or on public insurance (11.75% vs. 2.91%, p < 0.001) than persistent cold spots. Cold spot ZIPs had statistically higher percentages of children on private insurance plans (12.3% vs. 8.6%) (p = 0.001). There were significantly higher rates of Hispanic residents in hot spot ZIPs compared to cold spot ZIPs (53.32% vs. 20.65%, p < 0.001) and lower percentages of Asian residents (0.89% vs. 8.28%, p < 0.001). Persistent hot spot ZIPs did have a statistically higher rate of Caucasian residents than persistent cold spots, but this did not persist when broken out by gender. There was no difference in the percentage of Black residents overall or by gender between hot and cold spots. Hot spot ZIPs had lower median populations per square mile (29.00 vs. 2287.80, p < 0.001). Still, there was no difference in rural/urban designation by RUCA code, with the majority being urban-focused. 49 Ramphul et al. 10.3389/fpubh.2024.1418526 Frontiers in Public Health 04 frontiersin.org Discussion This study found significant geographic, gender, and socioeconomic disparities between persistent hot spots and persistent cold spots of HPV vaccination coverage in Texas. Persistent hot spots are more likely to bedisadvantaged neighborhoods, with lower Child Opportunity Index scores and subdomain scores, higher poverty rates, lower median household incomes, and greater percentages of children on public insurance or uninsured. They are also generally less densely populated than persistent cold spots and have higher percentages of Hispanic residents. Persistent cold spots of HPV vaccination, on the other hand, have significantly higher rates of Asian residents and are more densely populated. This finding aligns with studies documenting a “reverse disparity” in HPV vaccination, with higher rates among certain racial minorities and those receiving public insurance (21). It has been hypothesized, for example, that the El Paso region of Texas has such a high vaccination rate due to the perceived increased risk of HPV-related cancers in the community, leading to greater voluntary vaccination uptake (22). There also may bemore robust provider recommendations and vaccine outreach in areas perceived as at higher risk of HPV-related cancers. Our study affirms this reverse disparity among much of Texas but suggests that some underrepresented FIGURE1 Average percent of registrants (aged 9+) by ZIP in ImmTrac2, who received at least one dose of the HPV vaccine in Texas. FIGURE2 HPV vaccination hot and cold spots in Texas. 50 Ramphul et al. 10.3389/fpubh.2024.1418526 Frontiers in Public Health 05 frontiersin.org minority populations, notably communities of Asian residents in urban locations, may benefit from further analysis. Comparing our results with studies from other states, weobserve both similarities and differences. In New York, higher HPV vaccination rates have been reported among Hispanic and Black adolescents, aligning with our findings in Texas (23). However, these states did not exhibit the same extent of reverse disparity for male adolescents, suggesting that local cultural, socioeconomic, and policy factors might influence these patterns (23, 24). For instance, the study “Improving HPV Vaccination Rates in a Racially and Ethnically Diverse Pediatric Population” highlighted successful interventions that increased vaccination rates in a diverse population yet did not report significant gender disparities like those found in Texas (24). These differences underscore the importance of considering local context and tailored interventions when addressing HPV vaccination disparities across different regions. Several studies have observed a reverse disparity in HPV vaccination rates among Hispanic communities, similar to trends seen in cervical cancer screening. For instance, research has shown that Hispanic adolescents have higher HPV vaccination rates compared to their non-Hispanic white counterparts, likely due to targeted public health initiatives and community outreach programs (25). Similarly, in many states, Hispanic women constitute a significant proportion of the clients served by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), indicating effective outreach and utilization of services within this community (24). Studies have also FIGURE3 Persistent hot/cold spot ZIP codes for HPV vaccination in Texas, 2017–2021. 51 Ramphul et al. 10.3389/fpubh.2024.1418526 Frontiers in Public Health 06 frontiersin.org reported higher cervical cancer screening rates among Hispanic women, attributed to culturally tailored interventions and community health programs that address language barriers and provide patient navigation (26). These findings underscore the importance of culturally sensitive healthcare interventions in improving preventive health measures in Hispanic communities. However, addressing disparities in follow-up care and treatment remains critical to ensure comprehensive care for these populations. Regarding characteristics of persistent hot spot ZIP codes of HPV vaccination coverage, such as higher rates of children on Medicaid insurance and lower rates on private insurance plans, this may be representative of the general socioeconomic makeup of the TABLE1 Child opportunity index score analysis of persistent hot and cold spot ZIPs of HPV vaccination. Child opportunity index domains† Persistent hot spots Persistent cold spots p-value* Child opportunity index score, overall (median score) 2.0 4.0 <0.001 Males aged 9+ 2.0 4.0 <0.001 Females aged 9+ 3.0 5.0 0.003 Education domain (median score) 2.0 5.0 <0.001 Males aged 9+ 2.0 3.5 <0.001 Females aged 9+ 3.0 5.0 0.009 Health and environment domain (median score) 2.0 4.0 <0.001 Males aged 9+ 2.0 4.0 <0.001 Females aged 9+ 3.0 5.0 <0.001 Social and economic domain (median score) 2.0 4.0 <0.001 Males aged 9+ 2.0 4.0 <0.001 Females aged 9+ 3.0 5.0 0.026 †1, very low opportunity; 2, low opportunity; 3, moderate opportunity; 5, high opportunity; 6, very high opportunity. *Mann–Whitney U Test Significance Level (0.05). Bold text indicate statistically significant values. TABLE2 Demographic and socioeconomic characteristics of persistent hot spots and cold spots. ZIP code level characteristics Persistent hot spots Persistent cold spots p-value* Income Population below the federal poverty level (percentage, median) 17.4 7.1 <0.001 Males aged 9+ 17.6 9.5 <0.001 Females aged 9+ 12.2 8.4 0.007 Median household income (USD, median) 47,751 83,486.0 <0.001 Males aged 9+ 46,880 71,999.5 <0.001 Females aged 9+ 58,795 85,942 <0.001 Race/Ethnicity (percentage, median) Caucasian 87.8 73.3 0.025 Males aged 9+ 84.98 79.8 0.566 Females aged 9+ 88.3 73.3 0.459 African American 3.2 7.9 0.223 Males aged 9+ 4.6 5.1 0.842 Females aged 9+ 4.3 7.9 0.649 Hispanic 53.3 20.7 <0.001 Males aged 9+ 67.4 20.96 <0.001 Females aged 9+ 38.98 22.3 0.041 Asian 0.89 8.3 <0.001 Males aged 9+ 0.9 4.1 0.007 Females aged 9+ 0.7 8.6 0.035 (Continued) 52 Ramphul et al. 10.3389/fpubh.2024.1418526 Frontiers in Public Health 07 frontiersin.org communities (i.e., lower median household income). However, this may also bedue to vaccination benefits among federally sponsored insurance, notably the Vaccines for Children program, which provides the HPV vaccine at no cost to those who meet eligibility criteria (Medicaid or uninsured). The reflection on how private insurance may deter vaccination warrants a deeper discussion. Private insurance plans often have higher co-pays and deductibles compared to public insurance, which can discourage families from completing the HPV vaccination series. Studies have shown that individuals with public insurance or who are uninsured are more likely to receive vaccinations through public health programs, which often cover the full cost of vaccines (27). This financial barrier associated with private insurance plans may contribute to lower vaccination rates among insured individuals, highlighting the need for policy interventions to reduce out-of-pocket vaccination costs. More research is needed to understand the barriers to HPV vaccination among all populations, but coverage for all people, regardless of insurance status, should beprioritized. Importantly, our study highlights differences in adolescent HPV vaccination coverage hot spots among male adolescents versus female adolescents. There were many more hot and cold spots of HPV vaccination coverage among male adolescents, indicating more clusters of areas with high HPV vaccination coverage rates and low vaccination coverage rates. This suggests that across the state, HPV vaccinations are more widespread among female adolescents compared to male adolescents. Increasing vaccination strategies specifically targeting male adolescents, therefore, may bewarranted. Our study does have some limitations. Primarily, our data is from the ImmTrac2 system, an opt-in program that may not entirely represent the population. Additionally, the use of the ACS and COI data as population-based metrics may not be representative of the individuals receiving the vaccines. Wewere unable to obtain more specific demographic information on participants, which limits the analysis to an ecological approach (8). Finally, there is a notable discrepancy between our reported adolescent HPV vaccination coverage rates (21–23%) and those reported in the Nehme article of (30–40%) (8), which cited higher rates for Texas. This is because the Nehme article used data from the National Immunization Survey-Teen (NISTeen). NIS-Teen is a random digit dialing telephone survey of households in the U.S. plus provider-reported vaccination histories of teens whose parents participate in the phone survey and consent to having their teen’s vaccination providers contacted. While NIS-Teen data offers comprehensive and representative vaccination coverage estimates, it relies on sample-based estimates. Conversely, ImmTrac2 provides detailed and timely immunization records, beneficial for monitoring and program evaluation, but its opt-in nature leads to underrepresentation and variable participation, as it requires parental consent for minors, resulting in incomplete data. Nonetheless, ImmTrac2 maintains robust coverage of vaccines given to pediatric populations (14). To our knowledge, this is the first spatiotemporal analysis of HPV vaccination coverage in Texas. Modeling statistical hot spots of HPV vaccination and identifying ZIP codes that model as hot/cold spots 5 years in a row presents a thorough approach to understating HPV vaccination geographically in Texas. Few studies on HPV vaccinations utilize high spatial resolution data, like ZIP codes, which allow for integrating neighborhood-level data like the Child Opportunity Index and key American Community Survey variables. These data sources allow a better understanding of neighborhood context, which may affect vaccination behaviors. Understanding the spatiotemporal dynamics of HPV vaccination rates in a vast state like Texas can enable advocates to tailor messaging and outreach more effectively to promote vaccine uptake. Data availability statement Publicly available datasets were analyzed in this study. This data can befound at: https://www.dshs.texas.gov/immunizations/ TABLE2 (Continued) ZIP code level characteristics Persistent hot spots Persistent cold spots p-value* Insurance coverage of children (percentage, median) Medicaid 11.8 2.9 <0.001 Males aged 9+ 13.3 3.5 <0.001 Females aged 9+ 8.2 2.8 <0.001 Private 8.2 12.3 0.001 Males aged 9+ 7.9 9.9 0.029 Females aged 9+ 11.1 13.5 0.277 Uninsured 2.9 1.9 <0.001 Males aged 9+ 3.1 1.9 0.009 Females aged 9+ 3.02 1.9 0.150 Population density Population per square mile (median) 29.0 2287.80 <0.001 Males aged 9+ 41.5 168.9 0.012 Females aged 9+ 5.5 199.04 0.004 RUCA codes (median result)‡Urban-focused Urban-focused 0.445 Males aged 9+ Urban-focused Urban-focused 0.124 Females aged 9+ Urban-focused Urban-focused 0.649 *Mann–Whitney U Test Significance Level (0.05). ‡Categorized into four domains: Urban-focused, Large rural city, Small rural town, and Isolated rural. Bold text indicate statistically significant values. 53 Ramphul et al. 10.3389/fpubh.2024.1418526 Frontiers in Public Health 08 frontiersin.org what-we-do/programs; https://data.diversitydatakids.org/dataset/ coi30-2010-tracts-child-opportunity-index-3-0-database--2010census-tracts?_ga=2.105088003.1687438952.1713278005-6079392. 1713278005 Author contributions RR: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Resources, Software, Supervision, Visualization, Writing – original draft, Writing – review & editing. AZ: Conceptualization, Data curation, Formal analysis, Investigation, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing. SU: Project administration, Writing – original draft, Writing – review & editing. MD: Data curation, Investigation, Methodology, Writing – review & editing. CB: Formal analysis, Funding acquisition, Methodology, Resources, Validation, Writing – review & editing. Funding The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article. Acknowledgments The Joint Center on Geospatial Analysis and Health, A Collaboration of The University of Texas Health Science Center at Houston School of Public Health and The University of Texas MD Anderson Cancer Center, made possible by UTHealth Academic Excellence Endowment and donors to the University of Texas MD Anderson Cancer Center’s Annual Fund. Conflict of interest The authors declare that the research was conducted without any commercial or financial relationships that could potentially create a conflict of interest. Publisher’s note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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Improving HPV Vaccination rates in a racially and ethnically diverse pediatric population. Pediatrics. (2022) 150:e2021054186. doi: 10.1542/peds.2021-054186 25. Garcia S, Hopfer S, Amaro H, Tanjasiri S. HPV vaccine delay and refusal among unvaccinated Mexican American young adult women: a qualitative investigation of Mexican-born and US-born HPV vaccine decision narratives. J Behav Med. (2023) 46:88–99. doi: 10.1007/s10865-022-00326-1 26. Percac-Lima S, Benner CS, Lui R, Aldrich LS, Oo SA, Regan N, et al. The impact of a culturally tailored patient navigator program on cervical cancer prevention in Latina women. J Womens Health. (2013) 22:426–31. doi: 10.1089/jwh.2012.3900 27. Institute of Medicine (US) Committee on the Evaluation of Vaccine Purchase Financing in the UnitedStates. Financing vaccines in the 21st century: assuring access and availability. 3rd ed. Washington, DC: National Academies Press (US) (2003). 54 Frontiers in Public Health 01 frontiersin.org Determinants of pneumococcal vaccination dropout among children aged 12–23 months in Ethiopia: a secondary analysis from the 2019 mini demographic and health survey AyenewAssefa 1 *, TeklehaimanotKiros 2, MulatErkihun 2, AyneworkAbebaw 3, AyenewBerhan 4 and AndargachewAlmaw 3 1 Unit of Immunology, Department of Medical Laboratory Science, Debre Tabor University, Debre Tabor, Ethiopia, 2 Unit of Medical Microbiology, Department of Medical Laboratory Science, Debre Tabor University, Debre Tabor, Ethiopia, 3 Unit of Parasitology, Department of Medical Laboratory Science, Debre Tabor University, Debre Tabor, Ethiopia, 4 Unit of Hematology, Department of Medical Laboratory Science, Debre Tabor University, Debre Tabor, Ethiopia Background: Vaccination is a cost-effective public health program that helps reduce significant morbidity and mortality in children under the age of five. Worldwide, the number of vaccine-preventable causes of child death has significantly decreased since the Expanded Program of Immunization (EPI) was introduced. However, for a variety of reasons, 23 million children did not have adequate access to vaccines in 2020. Therefore, this study aimed to evaluate the determinants of pneumonia conjugate vaccine (PCV) dropout among children aged 12–23 months in Ethiopia. Methods: The study analyzed cross-sectional data obtained from the 2019 mini Ethiopian demographic and health survey. Multilevel binary logistic regression analysis was utilized, and the best fit model was chosen using the Akaike Information Criteria. The study comprised a weighted sample of 989 children aged 12 to 23 months. The study presented the Adjusted Odds Ratio (AOR) along with a 95% Confidence Interval (CI) to identify the significant factors influencing PCV dropout. Results: The PCV dropout rate was reported at 20.2% in this study. In the multilevel analysis, possession of a health card (AOR = 0.076, 95% CI: 0.019, 0.04), vaccination for PCV 2 (AOR =0.002, 95% CI: 0.023, 0.263), and region 7 (AOR = 6.98, 95% CI: 10.1, 48.31) were significantly associated with children’s PCV dropout. Conclusion: Having a health card, having received the PCV 2 vaccinations, and region were significant predictors of PCV dropout. Consequently, health education on immunization for all mothers and region-specific, customized public health interventions are needed to reduce the vaccination dropout rate. KEYWORDS vaccine, children, dropout, women, demographic and health survey OPEN ACCESS EDITED BY Graça S. Carvalho, University of Minho, Portugal REVIEWED BY Lance Edward Keller, University of Mississippi Medical Center, UnitedStates Collins Ouma, Maseno University, Kenya *CORRESPONDENCE Ayenew Assefa [email protected] RECEIVED 29 December 2023 ACCEPTED 21 June 2024 PUBLISHED 03 July 2024 CITATION Assefa A, Kiros T, Erkihun M, Abebaw A, Berhan A and Almaw A (2024) Determinants of pneumococcal vaccination dropout among children aged 12–23 months in Ethiopia: a secondary analysis from the 2019 mini demographic and health survey. Front. Public Health 12:1362900. doi: 10.3389/fpubh.2024.1362900 COPYRIGHT © 2024 Assefa, Kiros, Erkihun, Abebaw, Berhan and Almaw. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. TYPE Original Research PUBLISHED 03 July 2024 DOI 10.3389/fpubh.2024.1362900 55 Assefa et al. 10.3389/fpubh.2024.1362900 Frontiers in Public Health 02 frontiersin.org Introduction Pneumonia is an acute lower respiratory tract infection that damages the alveolar air space and lung tissue. For children under the age of five, pneumonia is the greatest cause of illness and mortality (1). Over 900,000 children died from pneumonia worldwide in 2016, making up around 16% of the 5.6 million deaths of children under five (2). With 50% of the global death rate for children under five caused by pneumonia, Sub-Saharan African nations carried the lion’s share of the burden. In sub-Saharan African nations, pneumonia is the leading cause of death, accounting for about 172 deaths per 1,000 live births (3, 4). In Ethiopia, pneumonia is the number one cause of death in the postnatal period as well as the primary cause of morbidity and mortality in children under the age of five. Each year, more than 40,000 children under the age of five die from pneumonia, which accounts for 20% of all causes of death (5, 6). Pneumonia, which causes significant morbidity and mortality in children under the age of five, is among the diseases that can beprevented by vaccination. Vaccination is a cost-effective public health program that helps reduce these rates. Worldwide, the number of vaccine-preventable causes of child death has significantly decreased since the Expanded Program of Immunization (EPI) was introduced in 1974 with the goal of boosting routine immunization coverage (7). Around 2 to 3 million children a year are saved through vaccination (8). By the end of 2021, the pneumococcal vaccine had been launched in 154 member states, and global third-dose coverage was anticipated at 51% (9). In November 2011, Ethiopia added the 10-valent pneumococcal conjugate vaccine (PCV 10) to its childhood immunization schedule with the help of Gavi, the Vaccine Alliance. In accordance with the national vaccination program’s three-dose schedule, children receive the shot at 6, 10, and 14 weeks of age (10). In accordance with World Health Organization (WHO) recommendations, children are deemed fully immunized when they have received the following vaccinations by the age of 12 months: BCG for tuberculosis, three doses of DPT-Hep B-Hib (diphtheria, pertussis, and tetanus), pneumonia-conjugate vaccine (PCV) and polio, two doses of Rota virus, and a measles shot (11). In 2011, the national immunization program added the three doses of PCV to the vaccination schedule (12). According to Ethiopia’s routine vaccination schedule, infants should begin receiving vaccinations at birth and finish them before turning 1 year old. This includes receiving a single dose of the Bacillus Calmette-Guerin (BCG) vaccine at birth or as soon as possible, as well as the first dose of the oral polio vaccine (OPV). Three doses of the OPV, Pentavalent, Rota1, Rota 2, and pneumonia vaccines are given at intervals of 4 weeks duration at the 6 th , 10 th , and 14 th weeks, respectively, and finally, the measles vaccine is given at the age of 9 months (13) (Table1). 90% national coverage and 80% district coverage goals were set by the Global Vaccine Action Plan and the EPI for the year 2020 (14). Even though immunization rates had increased, in 2020, some 23 million children still lacked sufficient access to the shot (15–17). By the end of 2020, 83% fewer children worldwide have received their childhood vaccinations than there were in 2019 (18). Around 60% of these children resided in low-and middle-income nations (19). According to data from an Ethiopian demographic health survey, 39% of children aged between 12 and 23 months in 2016 received all required vaccinations. Because of this, the country’s immunization rates are often below the threshold needed to create herd immunity and stop the spread of eight EPI-targeted diseases (20). Numerous studies have shown that factors such as home birth, residence, mother’s knowledge of immunization, home visits by health workers, distance to medical facilities, misunderstandings about the benefits of immunization, and lack of knowledge about vaccine contraindications were predictors for child immunization (21–23). Full immunization coverage in Ethiopia remained extremely low, at 33.3%, for all age-appropriate immunizations, including three doses of PCV, despite the government’s reform initiatives. In addition, there is a notable variation in immunization coverage across various parts of the country (24). Several studies have examined the numerous factors that may contribute to childhood immunization dropouts (25). To our knowledge, few studies have been done on the rates of measles and polio coverage, but there have not been any studies on PCV coverage or dropout rates using survey data from Ethiopia. Therefore, this study sought to evaluate the determinants of the PCV dropout rate in Ethiopia using the 2019 mini-DHS data. Methods and materials Data source and study subjects The 2019 Ethiopian mini demographic and health survey (EMDHS) data served as the data source for the analysis. It is the second EMDHS and the fifth DHS implemented in Ethiopia. The survey was conducted by the Ethiopian Public Health Institute (EPHI) in collaboration with the Central Statistical Agency (CSA), the Federal Ministry of Health (FMoH), financial and technical support from development partners, and technical assistance from the Inner City Fund (ICF). The survey was conducted from March 21, 2019 to June 28, 2019, based on a nationally representative sample that provided estimates at the national and regional levels and for urban and rural areas. Two administrative cities (Addis Ababa and Dire Dawa) and all nine regions of Ethiopia (Tigray, Afar, Amhara, Benishangul-Gumuz, TABLE1 Routine immunization schedule in Ethiopia. Vaccine Disease Age BCG Tuberculosis At birth Pentavalent Diphtheria, Pertussis, Tetanus, H. influenza type b, Hepatitis B 6, 10, 14 weeks OPV Polio At Birth, 6, 10, 14 weeks Measles Measles 9 Months Pneumonia-conjugate Vaccine (PCV) Pneumonia 6, 10, 14 weeks Rotarix (rotavirus vaccine) Rotavirus 6, 10 weeks Tetanus (TT) immunization for women in child bearing age Tetanus 1st contact pregnancy; +1 month, +6 months; +1-year, +1 year Abbreviations: ANC, Antenatal care; AIC, Akaike information criteria; AOR, Adjusted odds ratio; EA, Enumeration area; EMDHS, Ethiopian mini demographic and health survey; EPI, Expanded program of immunization; PCV, Pneumonia conjugate vaccine; TT, Tetanus toxoid; WHO, World Health Organization; GHS, Global Health Survey. 56 Frontiers in Public Health 01 frontiersin.org Exploring the relationship between vaccine hesitancy and mothers’ perspectives on COVID-19 vaccines for children ages 5–11 years during the omicron predominant period 2021–2022: a qualitative study TiffanyA.Suragh *, DavidAdzrago , MarlynA.Allicock , PaulG.Yeh and PaulaCuccaro Department of Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, United States Background: The United States Food and Drug Administration authorized COVID-19 vaccines for children ages 5–11 years in October 2021 during the Omicron predominant period. Parental vaccine hesitancy was prevalent during this time, resulting in low childhood COVID-19 vaccine uptake. Most studies exploring factors influencing parental vaccine hesitancy have focused on racial and ethnic minorities and lower socioeconomic populations; however, there is little knowledge of the drive drivers of vaccine hesitancy among White parents with higher education and socioeconomic statuses. Methods: We conducted semi-structured interviews with a sample of 15 White mothers of children ages 5–11 years in Atlanta, GA, between October– December 2021. Thematic analysis was performed using NVivo 12. Results: Mothers were college-educated, homeowners, and fully vaccinated against COVID-19. Key findings included decreased pediatrician’s recommendations for COVID-19 vaccines, reliance on information from specialized doctors and scientists, distrust in public health authorities, high risk-perception of COVID-19 vaccines, and low risk-perception of COVID-19 disease. Factors related to vaccine acceptance were altruism and practicality. Conclusion: This study adds to the sparse literature on reasons for vaccine hesitancy among White mothers of children ages 5–11 years with higher educational and socioeconomic status. Improving vaccine uptake among this group is critical for protecting the health of their children and other vulnerable populations. Tailored vaccine messaging and intervention are warranted to address their unique attitudes, beliefs, and behaviors. An enhanced understanding of the factors influencing subpopulations of parents can help vaccine policymakers and healthcare providers improve efforts to reduce vaccine hesitancy, particularly for new vaccines. KEYWORDS COVID-19, childhood vaccination, vaccine hesitancy, vaccine refusal, qualitative OPEN ACCESS EDITED BY Carlos Alberto De Oliveira Magalhães Júnior, State University of Maringá, Brazil REVIEWED BY Rita Gill Singh, Hong Kong Baptist University, Hong Kong SAR, China Ronaldo Adriano Ribeiro Da Silva, Universidade Federal da Integração Latino-Americana, Brazil *CORRESPONDENCE Tiffany A. Suragh Tiffany[email protected] RECEIVED 14 December 2023 ACCEPTED 11 June 2024 PUBLISHED 08 July 2024 CITATION Suragh TA, Adzrago D, Allicock MA, Yeh PG and Cuccaro P (2024) Exploring the relationship between vaccine hesitancy and mothers’ perspectives on COVID-19 vaccines for children ages 5–11 years during the omicron predominant period 2021–2022: a qualitative study. Front. Public Health 12:1355452. doi: 10.3389/fpubh.2024.1355452 COPYRIGHT © 2024 Suragh, Adzrago, Allicock, Yeh and Cuccaro. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. TYPE Original Research PUBLISHED 08 July 2024 DOI 10.3389/fpubh.2024.1355452 63 Suragh et al. 10.3389/fpubh.2024.1355452 Frontiers in Public Health 02 frontiersin.org 1 Introduction The coronavirus disease (COVID-19) pandemic has highlighted the implications of vaccine hesitancy on low vaccine uptake and acceptance (1). It has demonstrated vaccine hesitancy’s threat to individual and population-level protection against highly infectious diseases (1, 2). Vaccine hesitancy – the delay or refusal of a vaccine despite its availability – is associated with low COVID-19 vaccine uptake among children (3–5). COVID-19 has resulted in negative health outcomes in children, including multisystem inflammatory syndrome (MIS-C). This has resulted in hospitalizations and deaths in children ages 5–11 years (6, 7). Nearly 15.6 million children in the UnitedStates (U.S.) have tested positive for COVID-19 (7), with the highest number of cases occurring during the Omicron predominant period 2021–2022. The FDA authorized the Pfizer-BioNTech COVID-19 vaccine for emergency use in children ages 5–11 years on October 29, 2021 (8). COVID-19 vaccination is the most effective way to reduce children’s COVID-19 morbidity and mortality, yet vaccination coverage remains suboptimal, with White children having some of the lowest vaccination rates (45%) compared to Asian and Hispanic Children (75 and 49%, respectively) (9). Geographic differences in vaccination coverage also exist, with eight of the 10 states having the lowest vaccination coverage in the South (10). Vaccine hesitancy may explain the vaccination coverage disparities among children ages 5–11 years. Vaccine hesitancy strongly influences parents’ decisions to vaccinate their children and is a complex notion varying across vaccine types, times, and settings (3). The World Health Organization’s (WHO) Increasing Vaccination Model (IVM) proposes that vaccine uptake is based on people’s thoughts and feelings, such as perceived risks and benefits, and social processes, like social norms and information (11). In addition to these factors, practical issues such as vaccine cost and availability result in vaccine acceptance, delay, or refusal (11). Vaccine hesitancy is influenced by multiple interrelated factors, and some individuals may accept some vaccines and refuse or delay others (12). Reasons for parental COVID-19 vaccine hesitancy included the vaccine’s novelty and lack of confidence in its safety and efficacy (13– 18). For example, parents described that the vaccines were developed too quickly and were not well studied leading to concerns about unknown vaccine risks and potential side effects, such as myocarditis and fertility issues (14, 19, 20). The changing vaccine recommendations, including the need for boosters and vaccine dosage in children, also created confusion and doubt among parents regarding the necessity of childhood vaccinations (14–17, 21, 22). Studies found that vaccine-hesitant parents tended to have less knowledge of vaccines, leading to less confidence in the vaccine’s efficacy (19). Beliefs that COVID-19 was more severe in children with pre-existing conditions and adults led to vaccine hesitancy among parents who felt their children were healthy and did not feel compelled to protect the community at large (14–16). Distrust of government and public health officials also contributed to conspiracy theories and misinformation about the COVID-19 vaccine (13, 14, 17–20). This misinformation spread quickly through social media, where some parents seek vaccine information (18–20). These beliefs were persistent even among parents fully vaccinated against COVID-19 (13, 23). Vaccine hesitancy is also largely influenced by demographics such as race, income, and educational level (24, 25). A common belief is that vaccine-hesitant individuals are of lower income and educational status and occur mostly among racial and ethnic minorities (13, 25, 26). However, vaccine hesitancy is prevalent among White individuals and those with higher educational levels and socioeconomic status (24, 27). This may bedue to the environments in which they live and work, which might limit their exposure to large groups of people (e.g., crowded schools and houses) and influence their perceptions of disease severity. A Kaiser Family Foundation poll found that parents who are Black or Hispanic are less likely to feel their child is “very safe” from COVID-19 at school than White parents (33% vs. 52%) (28). Many studies examining parental perceptions of childhood COVID-19 vaccines have been quantitative (13, 16, 21–23), with few qualitative studies (14, 15, 29). Qualitative research allows the gathering of rich data and exploration of thoughts and feelings that enable researchers to gain insight into decision-making processes and help explain human behavior, including a mother’s decision to vaccinate their child against COVID-19 (30). To our knowledge, this was one of the few qualitative studies to explore maternal perceptions of COVID-19 vaccines for children ages 5–11 immediately after the FDA introduced the vaccine. Lastly, most of the literature has focused on drivers of vaccine hesitancy among racial and ethnic minorities and those with lower socioeconomic status (31–33). Limited information exists on factors influencing COVID-19 hesitancy among White, higher-income, and educated parents. It is critical to increase vaccine uptake among this subpopulation to protect their children and other vulnerable groups and increase vaccine uptake. The objective of the study was to understand the beliefs, attitudes, and behaviors of White mothers of high socioeconomic status and education levels regarding COVID-19 vaccination among children ages 5–11 years. Findings can have clinical and policy implications, such as better strategies to target different subpopulations of parents with unique vaccine hesitancy concerns and needs. 2 Methods 2.1 Participants We conducted semi-structured interviews with 15 mothers from October to December 2021. Weused purposive sampling to recruit mothers. The sample was recruited primarily from one childcare service/company that connects families with in-home care in Atlanta, GA, and the rest of the sample was obtained through snowball sampling. The lead author emailed the childcare service describing the study and asked if the information could bepassed to mothers. After each interview was completed, the lead author asked the participant to share information about the study with other mothers who might beinterested. Mothers were eligible to participate if they had a child ages 5–11 years, lived in Atlanta, GA, and spoke English. 2.2 Data collection We used semi-structured interviews to create dialog while allowing for emergent ideas (34, 35). Wedeveloped a semi-structured interview guide based on a literature review and consultation with experts in qualitative research and vaccine hesitancy, including faculty at the University of Texas Health Science Center at Houston (UTHealth Houston). Interview questions were not tied to a particular theory or 64 Suragh et al. 10.3389/fpubh.2024.1355452 Frontiers in Public Health 03 frontiersin.org framework to allow researchers to gather rich, complex data without being constrained by theoretical constructs. Mothers were asked broad, open-ended questions about their perceptions of routine and COVID-19 childhood vaccines. Questions centered around their views of COVID-19 vaccines and how this compared to routine childhood vaccines, trusted sources of COVID-19 vaccine information, perceptions of COVID-19 disease, and factors that would influence their decision to vaccinate their child against COVID-19. Verbal consent was received before the interviews. Interviews lasted 45–60 min and were audio and video recorded using Zoom (Zoom Video Communications Inc., 2016). Interviews were professionally transcribed verbatim, and transcripts were independently coded by a primary (TS) and secondary (DA) reviewer. A third reviewer resolved disagreements of codes (PC). 2.3 Data analysis Thematic analysis was performed and included deductive and inductive approaches using NVivo 12 software (released in March 2020) (36). Utilizing Braun and Clarke’s thematic content analytic approach, the researchers (TS & PC) first conducted multiple transcript readings that were discussed among the research team to develop a codebook that aligned with the research question and study objective (37, 38). Emergent themes were discussed among the researchers and used in revising the codebook. Analysis continued with the refinement of codes until saturation was met and no new codes or themes emerged (39). All study procedures were approved by the Committee for the Protection of Human Subjects (the institutional review board) at UTHealth Houston (HSC-SPH-11-0577). 3 Results 3.1 Sample In total, 15 mothers with children ages 5–11 years completed individual interviews. Participants were White, college-educated homeowners and the majority reported receiving two doses of COVID-19 vaccines for themselves. Participants’ ages ranged from 36 to 47 years (Table 1). Pseudonyms were used to describe the participants to protect the identity of the participants and because the sample was demographically similar (40). The majority of mothers were hesitant about COVID-19 vaccines, and their hesitancy was driven by the unfamiliarity and novelty of the vaccine, balancing the risks and benefits of the vaccine, distrust in government, science, and public health authorities, decreased trust in pediatricians and increased trust in medical specialists. Mothers who were accepting of COVID-19 vaccines had a greater fear of adverse effects of COVID-19 disease than the vaccine and wanted to return to normalcy with children in school and protect the greater community. The following themes emerged in relation to COVID-19 vaccine hesitancy and vaccine acceptance: 3.2 Vaccine hesitancy is influenced by the unfamiliarity and novelty of the vaccine Mothers described their unwillingness to vaccinate their children based on their level of familiarity and novelty surrounding COVID-19 vaccines. Routine vaccines for known illnesses such as influenza were viewed differently from emergent diseases like COVID-19. For routine childhood vaccines like the Rotavirus vaccine, mothers described confidence in the vaccines’ safety and efficacy due to the length of time the vaccines had been around and having been vaccinated themselves as a child. This familiarity resulted in mothers’ confidence and acceptance of routine vaccines as recommended by their pediatricians. Conversely, uncertainty and fear led to the nonacceptance of childhood COVID-19 vaccines. Mothers expressed the vaccine’s novelty, fast development, and unknown long-term side effects as reasons for low confidence in the vaccine. Paradoxically, mothers who were vaccinated against COVID-19 unwilling to vaccinate their children, and hesitant to follow their pediatrician’s recommendations as they normally would before the COVID-19 vaccine. Lauren expressed her views on routine and COVID-19 vaccines, … Ipretty much just followed the standard doctor’s guidelines. So, whenever…we had a doctor’s appointment when they were little kids…. Ialways consented to them to get the vaccines. Inever delayed…the vaccines that wehave done in the past have been around for such a long time, and so there’s a lot of, youknow, evidence that they are not harmful. And with…these [COVID-19] vaccines, they have come out so quickly, gotten through the approval process so quickly (Lauren, mother of 2 children). The fast approval and quick manufacturing of COVID-19 vaccines made mothers wonder if the vaccine risks outweighed the benefits. 3.3 Balancing the risks and benefits of childhood COVID-19 vaccination Some reasons underlying mothers’ hesitancy towards COVID-19 vaccines were due to unknown and potential long-term side effects, particularly their novelty and the short manufacturing times for these vaccines. Maria expressed concerns about possible side effects, I think it’s probably effective and safe. Because Ifeel like people, millions of people, hopefully, would not betaking it if it wasn’t. Iguess because it’s so new, wedo not know what any of the TABLE1 Demographic characteristics of mothers of children ages 5–11 years (N = 15).* Demographics N (%) % Age (years) 29–39 10 67 40–49 5 33 Education Bachelor’s degree 5 33 Graduate degree 10 67 Number of children 1–2 11 73 3–4 4 27 *Mothers were all White, owned their homes and were vaccinated against COVID-19. 65 Suragh et al. 10.3389/fpubh.2024.1355452 Frontiers in Public Health 04 frontiersin.org long-term side effects are. Like, is my son going to have fertility issues later? Is it going to affect his sperm? (Maria, mother of 2 children). These concerns outweighed any perceived benefit to vaccination. The belief that vaccinating children would protect them and the community did not motivate mothers toward vaccination. Rachel expressed her ambivalence about COVID-19 vaccines, I think it is one of the hardest decisions that I’ve ever had to make for my kids… weare not set on which way we’ll go right now… you just do not want to do anything to harm your kids…. And this, I’m not convinced weare doing it for the kids yet and that makes me really nervous, and Ido not want to make a bad decision for them…because it could affect them for the rest of their life. And there’s just so much unknown (Rachel, mother of 2 children). A sentiment expressed by mothers was that their children were not at risk for severe complications from COVID-19 because they were healthy and unexposed to large groups. Some mothers described having pods of 4–5 children that studied and played together when schools were closed and not having to bearound many people. Olivia shared her reasons for waiting to vaccinate, My children, luckily, do not have any problems other than being preemies. They are not obese. There are no tobacco users in our life. We’re very thankful not to have any of those sorts of risk factors. Wealso live in Atlanta, where wedo not ride public transportation on a regular basis…we are not exposed to big crowds, that kind of thing. It might bedifferent if Iwas taking a subway in NewYork City every day and come in contact with a lot of people, but, my plan is to wait at least two years… (Olivia, mother of 2 children). 3.4 Vaccine hesitancy influenced by distrust science Vaccine hesitancy was influenced by distrust in government and public health officials and increased trust in medical and infectious disease specialists. Mothers who were hesitant about childhood COVID-19 vaccines described their lack of confidence and trust in the scientific information disseminated to the public by the government, vaccine manufacturers, and public health officials. They were skeptical about the vaccine’s safety and efficacy due to the perceived lack of rigor in the scientific studies. Mothers did not think there was enough evidence to justify childhood COVID-19 vaccination and were not convinced vaccination was the decision for their children. Their ability to interpret scientific information independently influenced their trust and confidence in science. Sarah expressed her doubts, …this experience has dramatically changed my perspective on our medical institutions and the amount of trust Ihave in them in a major way…The sample size with kids for the Pfizer testing was… roughly, like, a little under 2,200. That, to me, is not a large enough sample with a large enough time period for me to sign my kid up… (Sarah, mother of 3 children). The changing and conflicting messaging by the public health authorities during the COVID-19 pandemic contributed to mothers’ uncertainty about the vaccine. Messages, like the length of time children needed to wait to bevaccinated after having COVID-19, the spacing of COVID-19 and other childhood vaccines, and face mask guidelines led to mothers’ doubting the accuracy of information channeled through traditional sources, including their pediatricians. Despite having established relationships with their pediatricians, mothers now felt them to beless trustworthy and knowledgeable of the efficacy and safety of childhood COVID-19 vaccines. Ashley stated, “…our doctor has been sending out emails every week about how safe the vaccine is. And Imean that’s great, but. And like how safe masking is for kids, but Ijust do not really, um, it’s just not to my taste. So, probably not her doctor…there are some news outlets that Ifind to becredible…” (Ashley, mother of 4 children). Alternatively, mothers relied on information from specialty doctors like cardiologists and infectious disease specialists. Unlike pediatricians, whom they felt would recommend the vaccine regardless of potential safety concerns, mothers felt specialists provided more honest and independent reviews of childhood COVID-19 vaccines. For example, mothers felt more comfortable speaking to cardiologists regarding the potential risk of heart inflammation (e.g., myocarditis and pericarditis) following COVID-19 vaccination. This reliance on specialists was facilitated by the proximity and access to these professionals, who were their neighbors, friends, and family members. Maria expressed her reasons for increased reliance on specialist doctors, “…I love their pediatrician, and wehave a really good relationship with him…I feel like the epidemiologist is closer to this specific focus…I know my doctor is not in the lab testing vaccines…he’s not on the front lines.” (Maria, mother of 2 children). This shifting trust in science influenced mothers’ perception of the severity of COVID-19in children and the risks associated with the COVID-19 vaccine. Mothers did not mention reliance on specialists for routine vaccines, and it appears this shift in perception was related to the novelty and unfamiliarity of the COVID-19 vaccine as well as based on their trusted sources of vaccine information. 3.5 Vaccine hesitancy influenced by trust in source of COVID-19 vaccination information A key driver of vaccine hesitancy among mothers was their level of trust in the sources of information promoting childhood COVID-19 vaccination. If mothers did not trust the information or agenda of institutions and authorities, they were less confident that the vaccine was the best decision for their children. Sources deemed trustworthy included scientific websites and organizations (e.g., the Mayo Clinic), news, podcasts, cardiologists, epidemiologists, family, and friends. While mothers mentioned viewing information on social media platforms like Facebook, they did not consider these platforms trustworthy or their primary source for vaccine information. They 66 Suragh et al. 10.3389/fpubh.2024.1355452 Frontiers in Public Health 05 frontiersin.org described the extent to which they would actively seek out information and make their conclusions about the vaccine (e.g., searching for adverse events following COVID-19 vaccination on publicly available government databases) instead of passively accepting information. Sarah described how she searched for credible information, … Iread the NewYork Times every morning, and Iread the AJC [The Atlanta Journal-Constitution] every morning…I also, youknow, Google things. And when IGoogle things, Itry to click websites that Irecognize and that are things like John Hopkins, Mayo Clinic…things that seem like they would not get away with misinformation… (Sarah, mother of 2 children). Mothers were also keenly aware that politics heavily influenced the dissemination of COVID-19 vaccine information. They described the differing opinions regarding childhood COVID-19 vaccines’ safety and necessity based on conservative versus liberal sources of information. The politicization of the COVID-19 pandemic led mothers to question the true motivations behind campaigns promoting childhood COVID-19 vaccinations and whether vaccines were being used for political gain rather than to protect their children’s health. This perception contributed to mothers’ reluctance to vaccinate as they refused to put their children at risk for unknown side effects due to political pressure, creating doubt about the veracity of the scientific information being used to promote the vaccine for children. Rachel expressed her concerns, …I do not trust the politics, and some of [the] encouragement to give it to them [children] is to protect adults who refused to get it themselves. And that’s not fair. Ido not want to do something to my kids that the studies have not been fully done on to protect adults, who are old enough to decide for themselves and have the free choice to do it or not, and it’s their fault if they do not. Icannot help that in my opinion. And I’m not gonna punish my kids because they [adults] do not [get vaccinated] (Rachel, mother of 2 children). 3.6 Vaccine acceptance influenced by fear of COVID-19 disease and wanting to return to normalcy The belief that COVID-19 vaccines could protect children and the community resonated with some mothers and affected their decision to vaccinate their children. Mothers who already vaccinated their children against COVID-19, or intended to, believed the benefits of vaccination outweighed the potential long-term risks of COVID-19 disease. Katherine expressed her concerns, …I’m really nervous about the long-term effects of my son getting COVID because…Like, what if it causes some lung issues and he’s not able to play soccer like hedoes…we kind of know right now from the trials that there’s not going to bethese really long longterm effects from the COVID vaccine, whereas Ido not feel like weknow that for actual COVID-19 infection…I do not think the COVID vaccine is going to make my son suffer, but Ido feel like COVID, potentially, in the long run, could make him suffer…” (Katherine, mother of 1 child). A minority of mothers accepted the vaccine for reasons like fewer missed school days and the ability to travel. They described older family members as more at risk for severe complications of COVID19, and vaccinating their children was a way to allow them to spend time with others safely. For these women, altruism and practical reasons outweighed the perceived risks associated with the vaccine. Allison expressed her considerations, … besides the health, there’s also the logistics. Like Ifeel like Iwork in a hospital, and they are at risk, and so Iwanted them protected. There’s also, at the schools, Iknow that there will bedifferent requirements for quarantining if there’s exposures, and if they have vaccines, then they will not have to quarantine, so there will not bemissed school…and all of that was really important to me. I do not want my kids learning virtually anymore, ever, if possible… (Allison, mother of 2 children). Regarding the logistics of traveling, Lauren stated, …we have some international travel coming up, so…we said, “Okay. Well, maybe we should go ahead and get the kids vaccinated…And it’s honestly less for the fact that youknow, we think it’ll prevent them from contracting [COVID-19 infection] or their symptoms, but more from the fact of, youknow, wedo not want any disruptions to the travel, to bequite honest… (Lauren, mother of 2 children). 4 Discussion Our study identified key factors related to vaccine hesitancy and acceptance of childhood COVID-19 vaccines among White, mothers of children ages 5–11 years from higher educational and socioeconomic backgrounds. Mothers who were vaccine-hesitant expressed unfamiliarity and fear of unknown adverse effects of COVID-19 vaccines, decreased trust in pediatricians’ recommendations, and distrust in science and public health authorities. Mothers who were vaccine-acceptant expressed sentiments including trust in the science and public health authorities, fear of COVID-19, and aspects of altruism such as wanting to protect their children, family, and community. Reasons for practicality and wanting to return to normalcy were also noted for accepting childhood COVID-19 vaccines. Our findings reinforce the notion that vaccine hesitancy is a complex phenomenon and vaccine decision-making is influenced by many contextual factors (3, 11, 12). Individuals cannot begrouped exclusively as “hesitant” or “acceptant.” Mothers in our study were hesitant to vaccinate their children with COVID-19 vaccines yet accepted routine childhood vaccines like polio and influenza. Mothers’ familiarity with routine vaccines, such as having taken these vaccines as children and understanding their safety profiles, influenced their decisions to vaccinate their children. This finding aligns with research that found parents accepting some but not all vaccines and mothers vaccinated against COVID-19, yet still hesitant for their children (12, 13, 23). The novelty of COVID-19 vaccines routine vaccines made 67 Suragh et al. 10.3389/fpubh.2024.1355452 Frontiers in Public Health 06 frontiersin.org mothers feel less confident in the vaccines’ safety and efficacy (13–18). Similar to other studies, most of the mothers in our study were fully vaccinated against COVID-19 but were still concerned about the vaccine’s safety in their children, for example, citing long-term fertility issues (13, 14). Our findings align with other vaccine trends that have shown demographic factors, including White, affluent, educated parents who are least likely to vaccinate their child against the human papillomavirus (HPV) and are a major group within the anti-vaccine movement (41–43). Despite this subpopulation having fewer potential barriers to vaccination (e.g., financial instability and lower education), their decision-making is influenced by their research, weighing the benefits and risks of vaccination, and personal beliefs values, and attitudes (44–46). In our study, mothers accessed, reviewed, and interpreted publicly available government datasets on adverse events following childhood COVID-19 vaccination to help them understand the vaccine’s safety and side effects. For example, mothers who believed the sample sizes of the clinical trials were small may feel more confident in their decision to vaccinate their child if they received detailed information on how to interpret sample size calculations and vaccine efficacy (45). This misunderstanding of COVID-19 scientific information being disseminated by the government and public health officials led to distrust in these entities and is a common theme in the literature. It is essential for policymakers to increase efforts to develop tailored materials that offer more transparent vaccine safety information for a subgroup of parents who are well-informed and access resources that most parents might not know exist (e.g., publicly available government surveillance databases). For example, vaccine messaging can include more technical information, such as how to interpret scientific data from clinical trials and government vaccine surveillance systems (44–46). These efforts can increase vaccine confidence and trust among parents. Studies have found pediatric healthcare providers to bethe most trusted sources of vaccine information and facilitators of childhood vaccine uptake (14, 21, 22, 44). Wefound contrasting evidence as mothers in our study expressed decreased trust in their pediatricians and increased reliance on medical specialists like cardiologists and epidemiologists for COVID-19 vaccine information. During the H1N1 pandemic, individuals also lost trust in the government and health authorities, decreasing their willingness to get vaccinated (47). Parental vaccine hesitancy is influenced by many factors, such as vaccine type and how it was introduced (e.g., during a pandemic or mass vaccination campaign) (44–46). It is essential to strengthen longstanding relationships between pediatricians and parents, especially during a pandemic, when parents may bemore concerned and less trusting of scientific information. Policymakers can consider how to develop tools to encourage collaborative provider-parent communication. Creating an environment where parents feel confident in the information received as opposed to feeling pressured to vaccinate their child against their will or despite their concerns can bebeneficial among subgroups of parents like those in our study (45, 48). The politicization of COVID-19 vaccines influenced mothers’ hesitancy towards vaccinating their children against COVID-19. Mothers expressed distrust in the true motivations of public health authorities recommending childhood COVID-19 vaccination. The belief that politicians misused COVID-19 vaccine information for their political gains aligned with research that suggested public confidence in COVID-19 vaccines was affected by how the government handled the COVID-19 pandemic (49). A poll by the Kaiser Family Foundation found political affiliation to bea stronger predictor of whether someone is vaccinated than demographic factors, such as education, race, and age (50). Considering how social, contextual and political factors may influence vaccine attitudes and beliefs, highlights the importance of public health officials leveraging multiple communication channels to address parental concerns (51). Mothers in our study mentioned podcasts and medical websites as trusted sources of information. Podcasts were preferred because they offered differing views of childhood vaccination, and mothers appreciated the neutrality of discussions. This neutrality countered the partisan bias typically found in traditionally conservative and liberal news. Interestingly, social media was not regarded as a source of vaccine information but rather just a place to socialize, contrasting the mounting evidence that misinformation on social media influences vaccine decisionmaking (18, 20, 52). For mothers similar to our sample, it may bemore effective to disseminate public health messaging regarding childhood COVID-19 vaccination through outlets not related to social media. Our findings also highlighted the nuances in parental and child COVID-19 vaccination status. While other studies found parents vaccinated or intended to vaccinate against COVID-19 also intended to vaccinate their children (13, 16), our study yielded different findings. The majority of mothers in our study were all vaccinated against COVID-19 and accepted the risks of vaccination for themselves. Yet some were still hesitant and unwilling to put their children at similar risk. Children ages 5–11 years are different than older age groups, such as adolescents who may have some autonomy around vaccine decision-making (15). Therefore, mothers of young children may feel an even greater responsibility for their child’s health. Similar to other studies, parental motivations for vaccinating their child against COVID-19 included a desire to protect the broader community, return to normalcy, and mitigate the negative social and emotional consequences of COVID-19, such as educational losses due to missed school (14, 16). Mothers expressed getting their children vaccinated so they could travel internationally, and it would appear that the familial and logistical benefits of vaccination would outweigh any perceived risks associated with the vaccine. Mothers in our sample were highly affluent and may have different motivations for wanting their child vaccinated than less affluent mothers Also, policymakers may want to emphasize the importance of school-based interventions and immunization policies that can encourage vaccine uptake in children (53). Vaccine hesitancy can be conceptualized as linear stages of hesitancy and non-hesitancy based on the Increasing Vaccination Model and the Precaution Adoption Process Model (11, 54, 55). Some mothers in our study would fall within the stages of undecided (i.e., considered but not yet decided) and refuse (i.e., considered and decided to refuse). A notable difference with our findings is that the process may not belinear. For example, some mothers immediately refused childhood COVID-19 vaccines without first being undecided. This behavior highlights the complexities of understanding vaccine hesitancy. There is a public health need to shift mothers from undecided to decided, and understanding the perspectives of mothers who may have fewer financial barriers and access to more resources, 68 Suragh et al. 10.3389/fpubh.2024.1355452 Frontiers in Public Health 07 frontiersin.org such as those who are highly educated, can help in tailoring policydriven interventions. For mothers who accepted COVID-19 vaccines, according to the model above, some would still be classified as “decided but not yet highly educated” due to delays in getting their child vaccinated. These mothers described technical barriers like being put on a waitlist to see their doctor. Despite the variety of places where COVID-19 vaccination is available, it is possible that mothers feel more comfortable vaccinating their children in a pediatrician’s office or a school setting. This preference may inform policy decisions related to vaccine distribution and understanding how these barriers may bereduced to facilitate faster vaccination for willing parents. 4.1 Strengths and limitations Our qualitative approach allowed for a deeper exploration of White mothers of higher educational and socioeconomic statuses’ perspectives, producing rich data that offer more context than quantitative survey data. While studies have highlighted influencers of vaccine hesitancy among minority populations, very few have focused on higher socioeconomic populations. Wefound mothers with higher educational and financial status hesitant to vaccinate their children ages 5–11 years against COVID-19. This finding suggests that parents of various backgrounds have different beliefs and values, and future public health efforts should consider this when promoting vaccine uptake. These differences are especially critical during the early months of a vaccine’s rollout during a pandemic when many lives are at risk (47, 56, 57). Our qualitative study is one of the few studies that occurred when the FDA authorized the Pfizer-BioNTech COVID-19 vaccine for emergency use in children ages 5–11 years and represented early views and perceptions. Additionally, COVID-19 vaccine uptake in children ages 5–11 years remains suboptimal, with White children having the third lowest vaccination coverage. These findings may help explain why White parents of higher educational and socioeconomic status might still behesitant. Limitations of our study include that our sample was purposively recruited from one setting, a childcare service, and represents one geographic location, Atlanta, GA. The sample comprised of White, highly educated, higher-income mothers from the South. Their perspectives are not generalizable to other mothers. Wefocused on mothers because they tend to beprimary healthcare decision-makers for children, including vaccinations (41); however, not having the perspectives of fathers or other caregivers limits the conclusions wecan draw from our findings. Our study took place at the beginning of the vaccine rollout for children ages 5–11 years, and it is possible that mothers’ perceptions changed over time. 4.2 Future recommendations Our study demonstrates the need to develop tailored public health interventions, vaccine policies, and clear and transparent communication strategies to address the unique needs and concerns of subgroups of parents. Understanding how demographic factors, such as race, income, and education, may influence vaccine hesitancy may inform different strategies to shift attitudes and beliefs toward accepting childhood COVID-19 vaccines. Mothers in our study were informed about childhood COVID-19 vaccines by researching scientific websites, reading clinical trial information, talking to medical specialists who were their friends and families, and reviewing data from government surveillance databases. Developing an intervention that could connect mothers with medical and infectious disease specialists and scientists may bebeneficial in addressing their concerns and countering misinformation. These interventions could potentially assist mothers with interpreting scientific information accurately, including understanding the limitations of surveillance systems. Mothers in our study did not rely on social media as trusted sources of information, and therefore, werecommend promoting vaccine information and engaging with parents through their preferred communication channels, such as podcasts. Future research is warranted to study vaccine hesitancy perspectives of other parents with higher education and socioeconomic statuses and from different geographical regions to see if similar patterns exist. 5 Conclusion Vaccine hesitancy may influence a mother’s decision to delay or refuse to vaccinate their child against COVID-19 and may be influenced by demographic factors such as race, income, and educational attainment. Our study highlighted the unique vaccine concerns and needs of White mothers with higher educational and, socioeconomic status an understudied group. Most studies have focused on the driver of parental vaccine hesitancy among racial and ethnic minorities and those with lower socioeconomic status. Mothers in our study conducted their own research and reached out to members of their social network who were medical specialists such as cardiologists. They preferred discussing vaccine safety information, such as the potential long-term effects, with these specialists rather than their pediatricians and primary care providers. This is concerning, given that previous studies have found that recommendations from pediatricians are the most impactful on vaccine receipt (54). It suggests the need for more tailored vaccine communication strategies and interventions, such as connecting these parents with scientists, epidemiologists, and medical specialists who can answer their questions and help them understand the risk–benefit ratio of COVID-19 vaccines. Our sample did not rely on social media for vaccine information, and policymakers may need to increase their presence on alternative platforms, such as podcasts, to counter misinformation. Vaccine-hesitant parents are a heterogeneous group, and understanding the beliefs, attitudes, and behaviors of subpopulations of parents is critical in reducing vaccine hesitancy and increasing COVID-19 vaccine uptake. Findings from our study revealed initial perceptions of childhood COVID-19 vaccines for children ages 5–11 years and can inform vaccination policies and health promotion guidelines surrounding the introduction of novel vaccines for emerging diseases. Data availability statement The datasets presented in this article are not readily available because it consists of audio and video recordings of interviews with participants. Wewant to protect the confidentiality and privacy of the participants. Upon request wemay beable to provide summaries. 69 Suragh et al. 10.3389/fpubh.2024.1355452 Frontiers in Public Health 08 frontiersin.org Requests to access the datasets should bedirected to TS, tiffany. [email protected]. Ethics statement The studies involving humans were approved by the Institutional review board at UTHealth Houston (HSC-SPH-11-0577). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Author contributions TS: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. DA: Formal analysis, Writing – review & editing. PY: Writing – review & editing. MA: Conceptualization, Formal analysis, Supervision, Writing – review & editing. PC: Conceptualization, Formal analysis, Methodology, Resources, Supervision, Writing – review & editing. Funding The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. TS was supported through a predoctoral fellowship, the UTHealth School of Public Health-NCI Cancer Control Research Training Program (National Cancer Institute/T32CA057712, MPI: P. D. Mullen, M. E. Fernandez, S. W. Vernon). Acknowledgments We would like to acknowledge the participants of the study who were open to sharing their perspectives during the COVID-19 pandemic and Sherly McCurdy from the University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Department of Health Promotion and Behavioral Sciences, for her guidance. Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could beconstrued as a potential conflict of interest. Publisher’s note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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(2020) 52:737–41. doi: 10.1016/j.immuni.2020.04.012 71 Frontiers in Public Health 01 frontiersin.org Community Health Volunteers’ experiences of implementing COVID-19 vaccine education and promotion in Kenya: a qualitative descriptive study Constance S.Shumba 1 *, PetersonKiraithe 2, IsabelKambo 2 and SheilaShaibu 2 1 Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, United States, 2 School of Nursing and Midwifery, Aga Khan University, Nairobi, Kenya Background: Vaccination was a key measure in the COVID-19 pandemic response, though much work was needed to promote vaccine uptake and acceptance. In Kenya, Community Health Volunteers (CHVs) played a key role in vaccine education and promotion. Weconducted this study to explore CHVs’ experiences of implementing COVID-19 vaccine education and promotion during the pandemic to increase COVID-19 vaccine uptake in two areas of Kenya. Methods: In a qualitative descriptive study, we conducted 30 structured indepth interviews with 20 CHVs and 10 Community Health Assistants from rural Kilifi County and Kangemi, an urban informal settlement of Nairobi County in Kenya between April 2022 and July 2022. Findings: Thematic analysis generated five key themes in relation to CHVs’ experiences of implementing COVID-19 vaccine education and promotion: Five key themes emerged regarding CHVs’ experiences of implementing COVID-19 vaccine education and promotion: (1) vaccine preferences influenced acceptance, (2) the fear of side effects was a barrier, (3) misinformation was widespread (4) lack of trust in government and politicization of vaccines was a barrier, and (5) CHVs’ efforts were a facilitator to increased uptake. Conclusion: Extensive community outreach from CHVs contributed to the high uptake of primary vaccines and boosters during the COVID-19 pandemic. CHVs acting as role models by receiving vaccinations first was particularly important in influencing communities to accept vaccinations. Findings provide evidence for prioritizing CHVs in the planning and implementation of future vaccination initiatives in Kenya and other countries. KEYWORDS Community Health Volunteers, COVID-19 vaccination, vaccine uptake, pandemic, Kenya OPEN ACCESS EDITED BY Carlos Alberto De Oliveira Magalhães Júnior, State University of Maringá, Brazil REVIEWED BY Miguel Landa-Blanco, National Autonomous University of Honduras, Honduras F. R. Lendacki, Chicago Department of Public Health, UnitedStates *CORRESPONDENCE Constance S. Shumba [email protected] RECEIVED 25 March 2024 ACCEPTED 21 June 2024 PUBLISHED 10 July 2024 CITATION Shumba CS, Kiraithe P, Kambo I and Shaibu S (2024) Community Health Volunteers’ experiences of implementing COVID-19 vaccine education and promotion in Kenya: a qualitative descriptive study. Front. Public Health 12:1406959. doi: 10.3389/fpubh.2024.1406959 COPYRIGHT © 2024 Shumba, Kiraithe, Kambo and Shaibu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. TYPE Original Research PUBLISHED 10 July 2024 DOI 10.3389/fpubh.2024.1406959 72 Shumba et al. 10.3389/fpubh.2024.1406959 Frontiers in Public Health 08 frontiersin.org with individuals who have been vaccinated being encouraged to share their experiences to increase trust and confidence in the vaccine. Community leaders and influencers may play an important role in setting a good example for others to follow. Further, it is crucial to communicate possible adverse reactions and the steps that should betaken in such instances. Misinformation was another factor preventing vaccine uptake. Reports indicated that many believed COVID-19 to bea hoax, an observation that is consistent with findings from Tanzania, Turkey, and the U.S. (31–33). To address misinformation and disinformation, public health officials and healthcare practitioners must prioritize the distribution of correct information. Incorrect beliefs can bedispelled by working with community leaders and influencers to deliver clear information regarding vaccination benefits and safety. Open forums and educational workshops, for example, can address concerns and give evidence-based responses to enable informed vaccination decision-making. Accurate information, community participation, and compassionate communication can help improve public health outcomes. Lack of trust in the government was also a major hurdle, according to CHVs. This is consistent with findings from a study conducted across countries which found Kenya to rank highest in the correlation between lack of trust in the government and non-acceptance of the vaccine (34). A similar association has been shown in China (35, 36). Belief in conspiracy theories, such as vaccines being state-backed interventions, decreased trust in vaccines and restricted uptake (37, 38). It is important that trust between government and citizens is continuously cultivated and that steps are taken to address sources of mistrust. Campaigns to depoliticize vaccination can help restore faith in government action. Relationships between communities and trusted workers such as CHVs can bevital in this endeavor. Findings indicated that CHVs were rightly prioritized for COVID-19 vaccination alongside other frontline health workers. This is consistent with WHO guidance (4). CHVs were actively involved in promoting vaccine uptake, with most reporting uptake rates of 80% and above in their communities. Their participation in promoting vaccination, conducting sensitization programs, and providing accurate information had a substantial influence. Through being prioritized, they were able to role-model being vaccinated and encourage communities to also do the same. Similarly, in other contexts, by highlighting the importance of COVID-19 vaccines and showing confidence in them, CHWs positively impacted community uptake (4, 14), with evidence supporting that vaccinated healthcare workers are more likely than unvaccinated ones to encourage the public to receive vaccination (14, 39). CHVs also engaged with the community as trusted members to deliver accurate information on COVID-19 vaccination uptake and sharing success stories of CHVs who had received the vaccine was important in increasing vaccination uptake and counteracting unfavorable narratives. An implication is that vaccination hesitancy can be tackled through focused communication techniques. Strengths and limitations This study contributes to a significant research gap regarding LMICs such as Kenya where the experience of CHVs in promoting COVID-19 vaccine uptake is not well-studied. The questions covered during the interviews enabled establishment of rapport, and guided robust understanding of the overall work of CHVs during the pandemic and how they experienced their work with communities specifically in promoting COVID-19 vaccine uptake. Our findings have the potential to guide the development of risk communication and community engagement materials and inform guidelines and policies on vaccine uptake and acceptance, not only during pandemics but also in routine immunization programs. Recruitment of urban and rural participants is also a strength of our study and for each theme, a comparison of the findings between the two distinct geographical areas has been made. Despite these strengths, interpretation of our findings may belimited by the study being conducted in just two of 47 counties in Kenya. Also, there is diversity in the experiences of CHVs and our findings may not reflect the perspectives of all CHVs across the country. That said, although findings may not begeneralizable to the entire country, they might betransferable. Furthermore, although we did data source triangulation between CHVs and CHAs, a limitation was the lack of triangulation to corroborate findings from CHVs with those from community members. Representation of communities’ own narratives would have deepened understanding of how vaccine education and promotion was experienced by community members and would have enhanced the credibility and validity of our study findings. In addition, a limitation to note is that there was no pre/post-intervention study or measurement here to evaluate whether use of CHVs was associated with improved vaccine coverage. Future research should focus on building upon the findings of this exploration, potentially deploying a mixed methods approach. Further, future studies should focus on co-creating and testing the feasibility of risk communication and community engagement models led by CHVs and their communities, that have a higher likelihood of success in increasing adoption of global guidance and addressing the barriers uniquely identified in the pandemic context. Conclusion and recommendations This study affirms the important role CHVs played in mobilizing communities to take up primary vaccines and boosters during the pandemic through vaccine education and promotion. CHVs acting as role models by receiving vaccinations first was a particularly strong driver of community uptake. Our findings support the need to tailor risk communication and community engagement to address myths and misconceptions, while also leveraging factors that can promote vaccination uptake such as the established positive and trusted relationships with CHVs. Further, the findings demonstrate the importance of prioritizing CHVs in the planning and implementation of future vaccination initiatives in Kenya and similar countries. Finally, the findings reveal underlying issues of public trust toward vaccination drives. This points to the crucial role of continual education and awareness raising in communities on the importance of vaccines, increasing the likelihood of vaccine uptake in situations of health crisis such as COVID-19. 79 Shumba et al. 10.3389/fpubh.2024.1406959 Frontiers in Public Health 09 frontiersin.org Data availability statement The original contributions presented in the study are included in the article/supplementary material, further inquiries can bedirected to the corresponding author. Ethics statement The studies involving humans were approved by Aga Khan Kenya’s Institutional Scientific and Ethics Review Committee [Ref: 2020/ IERC-89(v3)] and the National Commission for Science Technology and Innovation (EOP/NMS/HS/088). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Author contributions CS: Conceptualization, Formal analysis, Funding acquisition, Methodology, Validation, Writing – original draft, Writing – review & editing. PK: Data curation, Formal analysis, Investigation, Validation, Writing – review & editing. IK: Methodology, Validation, Writing – review & editing. SS: Conceptualization, Funding acquisition, Methodology, Supervision, Validation, Writing – review & editing. Funding The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article. Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could beconstrued as a potential conflict of interest. Publisher’s note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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(2021) 9:119. doi: 10.3390/vaccines9020119 81 Frontiers in Public Health 01 frontiersin.org One Health education for criticality on vaccination in teacher training InésMartínez-Pena 1 *, BlancaPuig 1 and AraitzUskola 2 1 Faculty of Education, Universidade de Santiago de Compostela (USC), Santiago, Spain, 2 Department of Didactics of Mathematics and of Experimental and Social Sciences, University of the Basque Country (UPV/EHU), Leioa, Spain Introduction: Vaccines are the basis of health of our communities since they prevent severe infectious diseases. However vaccination rates continue to decrease due to the spread of misinformation about their side effects, which enhances vaccine hesitancy and puts at risk public health. Introducing vaccines from the One Health approach can help to develop an integral understanding of their role and to apply critical ignorance as part of criticality to avoid vaccine hesitancy and raise trust in science. This paper presents a design on vaccination for secondary-education teacher training developed toward this goal. Methods: The design presented in this paper draws from previous studies on critical thinking, on vaccine rejection, and the One Health approach on other health issues in Secondary Education. The focus of this design is engaging secondary-education pre-service teachers in the practice of critical ignorance and criticality to assess diverse pieces of information on vaccination from the One Health approach. Results: This study discusses the design principles and the activities of an original design that aims to provide Secondary Education teachers with some tools to introduce critical ignorance and criticality for addressing misinformation on vaccines by using the One Health approach. Discussion: If secondary science teachers are going to successfully confront misinformation on vaccination in their science instruction, we need to develop and test designs and approaches that prepare them for this purpose. Critical ignorance plays a central role in managing misinformation; thus, such instruction should engage future teachers in critical evaluation of information on vaccination, as well as in the application of the One Health approach to take responsible actions. KEYWORDS One Health, vaccines, criticality, critical ignoring, biology education, teacher training 1 Introduction Since their discovery vaccines have contributed to save millions of lives throughout History and allowed the eradication of devastating diseases (1, 2). Recently, the COVID-19 pandemic highlighted the relevance of vaccination. It is estimated that COVID-19 vaccines contributed to save around 1.4 million lives in Europe between December 2020 and March 2023 (3). OPEN ACCESS EDITED BY Graça S. Carvalho, University of Minho, Portugal REVIEWED BY Becky Sparks-Thissen, University of Southern Indiana, UnitedStates Gaganjyot Kaur, Guru Nanak Khalsa College of Art, Science and Commerce, India *CORRESPONDENCE Inés Martínez-Pena [email protected] RECEIVED 29 March 2024 ACCEPTED 11 July 2024 PUBLISHED 26 July 2024 CITATION Martínez-Pena I, Puig B and Uskola A (2024) One Health education for criticality on vaccination in teacher training. Front. Public Health 12:1408965. doi: 10.3389/fpubh.2024.1408965 COPYRIGHT © 2024 Martínez-Pena, Puig and Uskola. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. TYPE Curriculum, Instruction, and Pedagogy PUBLISHED 26 July 2024 DOI 10.3389/fpubh.2024.1408965 82 Martínez-Pena et al. 10.3389/fpubh.2024.1408965 Frontiers in Public Health 02 frontiersin.org Despite the relevance of vaccines to preserve health, there is a concerning growth of vaccine hesitancy among population (4). This is fostered by the quick spread of fallacies and fake-news and increases the likelihood of preventable-disease outbreaks. Education in vaccines is an essential tool to raise awareness about the importance of vaccination and to fight against misinformation. Understanding how vaccines work and why they are important is a complex task that requires considering several dimensions of the problem besides human health. Consequently, vaccine education should integrate approaches that allow the development of a global view of the problem. One Health (OH) is an approach that considers the health of humans, animals, and ecosystems as interdependent, providing a global view of complex health issues, such as vaccination. Assessing vaccination and managing misinformation also requires the application of critical thinking (CT) skills, especially, critical ignoring (CI) and criticality. CI is the ability to select the information, and avoid low-quality information to control own’s informational environment (5). This will help citizens not only to develop their own opinion based on scientific evidence, and to differentiate evidencebased information from pseudoscientific claims, but also to take actions according to their opinion, putting CT in practice by committing to individual and collective actions, as the concept of criticality points out. The literature review showed that most approaches that introduce vaccination in health education limit to focus on human health, without considering environmental factors that affect this issue (6). This study seeks to make a relevant contribution on this and is in line with current trends regarding the understanding of health as a global issue that not only involves humans, but also the health of animals, plants and ecosystems, a view that is coherent with the OH approach (7). This design seeks to help teachers to promote an integral OH view of vaccination, and to use teaching strategies for managing information and to make responsible actions. 2 Didactical framework 2.1 Educational challenges to promote criticality on vaccination Even though the benefits of vaccination are widely supported by scientific evidence, vaccine hesitancy is a current concern in our society. Vaccine hesitancy was defined by the World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) on Immunization as: “Vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite availability of vaccination services. Vaccine hesitancy is complex and context specific varying across time, place and vaccines. It includes factors such as complacency, convenience and confidence.” (8) (p.575). Vaccine hesitancy includes people who show low or no confidence in vaccines but may support vaccination in certain situations and/or contexts. Anti-vaccine movements are located on one extreme of the continuum of vaccine hesitancy. Anti-vaccine individuals deny the efficacy of vaccines, totally rejecting their use independently on the context and circumstances (9). One of the main concerns of vaccine-hesitants and anti-vaccine individuals is the safety of vaccines (10). This lack of trust is enhanced by the spread of fallacies with no scientific evidence (e.g., vaccines cause autism, contain compounds that poison us, it is better the natural immunity than the immunity generated by vaccines, mRNA vaccines modify our genome…) (11, 12). In the post-truth era, vaccine misconceptions and fake news are quickly spread by social media promoting hesitancy (4, 13). This leads to a reduction in vaccine coverage among the population increasing the risk of preventable-disease outbreaks. Diseases that have long ceased to bea problem (e.g., measles) are currently experiencing outbreaks due to undervaccination in developed countries like the US and Europe (14, 15). This also shows the existence of a reducing level of trust in science. The low trust in science might beenhanced by a wide range of factors, such as complex and abstract scientific vocabulary, low ability to manage the uncertainty inherent to the construction of scientific knowledge, and the lack of knowledge regarding the Nature of Science. Moreover, the spread of fake news affects how people deal with scientific information. Science educators seek to promote trust in science taking into consideration these challenges, as well as misconceptions that have been already identified in the literature on vaccination (12). This design aims to provide teachers with tools to introduce efficient strategies for managing information to avoid misinformation and promote trust in science. 2.2 OH education for the practice of criticality in the context of vaccination Raising awareness about vaccination and reducing hesitation is one of the main goals in health education. Health education is part of the biology curriculum in Secondary Education (12–16 years old) in our country (blinded for review). However, health problems have been introduced as human centered SSIs, without an explicit connection with the environment. In response to this, and according to the new science curriculum (blinded for review) that includes the OH approach, science educators need to promote health education from a systemic perspective aligned with the OH approach to improve teachers’ and students’ understanding of vaccination from an integral view (16–18). This is the approach followed in this design. A deep understanding of the socio-scientific dimensions of vaccination and their potential to keep the health of a community requires the development of the OH approach. OH claims that the health of humans, animals, and ecosystems (including plants) are closely interdependent (7). Introducing the OH approach to teach vaccination will allow to comprehend the impact at different levels derived from an individual action (refuse vaccination). Such consequences would bedifficult to identify from a human-centered vision. Tackling health problems from the OH approach requires coordination between different social and professional sectors, including education. In fact, there are current initiatives to assess vaccination from the OH approach (19) but few of them are being developed in science and health education. Teaching the importance of vaccines should beoriented toward empowering students to make informed decisions and take individual and collective actions (10). This is an essential part of health literacy and criticality. A high development of health literacy requires the 83 Martínez-Pena et al. 10.3389/fpubh.2024.1408965 Frontiers in Public Health 03 frontiersin.org development of CT oriented to action, which corresponds to the notion of criticality. The CT is essential to deeply understand complex phenomena, allowing the development of an independent opinion, thus empowering students (20). As shown by Authors (blinded) (10), promoting CT skills along with knowledge about vaccines would help students to perform better decision-making and develop actions according to current scientific knowledge, avoiding pseudoscientific and non-scientific premises. As Davies and Barnett (21) pointed out, teaching CT in higher education involves considering at least six CT dimensions: (1) core skills in critical argumentation (reasoning and inference making); (2) critical judgements; (3) CT dispositions and attitudes; (4) critical being and critical actions; (5) societal and ideology critique; (6) critical creativity or critical openness. This work is focused on the second dimension, since critical judgment is essential for a suitable decisionmaking, and the fourth dimension as it is the most related to criticality. The term criticality involves CT and attends to the individual identity and the critical action dimension (21). Criticality promotion among students requires the development of complex and global views regarding an issue and weargue that OH could provide the integrated view required to effectively develop criticality regarding vaccination. Decision-making and action development require differentiating truthful information from non-scientific ideas. For this, critical ignorance (CI) is essential (22). CI can bedefined as the conscious decision about ignoring part of information deliberately by selecting and filtering information to minimize the exposure to low-quality information (5). Although CI is fundamental in the post-truth era, most of the literature on vaccines and CT are based on knowledge and evidence-based argumentation to encourage critical decision-making. Despite agreeing that some extent of fundamental knowledge is needed for CT application, it is not always possible for students to have a highly-specific knowledge on each SSI. This is something that Secondary Education teachers should take into consideration and that this design addresses. Therefore, it is necessary to provide instruction for pre-service/ in-services Secondary Education teachers about how to develop the OH approach regarding vaccination to foster CI, and Criticality among their students. 3 Learning environment 3.1 Learning objective The objective of this design is to engage Secondary Education pre-service teachers in the practice of criticality with a focus on CI to assess information on vaccination from the OH approach. Specifically, it is aimed to: 1. Explore how OH influences the understanding of vaccination. 2. Analyze how CI is mobilized to manage information about vaccination. 3. Assess how OH and CI are articulated in the practice of criticality when assessing information on vaccination. Objective 1 can beevaluated in Modules 1, 5; objective 2in Modules 2, 3, 5; while objective 3in Modules 4, 5. 3.2 Participants This proposal is designed to beimplemented with Secondary Education pre-service teachers with a scientific background (e.g., a degree in Biology, Geology, Chemistry, Physics, Pharmacy …) who are doing a master’s degree in science education in which health controversies are addressed as part of their training in socio-scientific instruction. These pre-service teachers do not have previous experience in the classroom and this training is the first contact with science education topics and vaccination from the OH approach. The design will beimplemented within the subject “Didactic Designs on Science Education” during the next school year 2024– 2025. Ethical considerations will becontemplated during this process of implementation and data analysis according to current legislation. 3.3 Design principles Most of the learning environments and designs proposed in the literature to foster CT are mainly focused on the use of SSIs as a context to promote critical argumentation, due to their complex and controversial nature (23, 24). SSIs related to biology and environmental education, such as vaccination, are considered privileged contexts to foster CT development (25). These designs are mainly based on the CT framework proposed by the Delphi study of Facione (26) and in the notion of CT provided by Kuhn (27) that consider CT a dialogical practice. According to Facione CT involves several cognitive skills, affective dispositions and domain-specific knowledge. Facione’s framework is frequently used as an operative tool for teachers training in CT (28, 29). Although weagree with the Facione (26) framework, current citizens are exposed to large amounts of information, some of which can constitute mis−/dis−/mal-information. Thus, teachers must encourage the skills to manage all this information to make decisions and take actions, even when there is low domain-specific knowledge of a certain SSI. This leads to the need to foster CI along with CT in science education (5, 22, 30). This design provides tools to put in practice CI in science education (Modules 2, 3). Osborne and Pimentel (31) propose a workflow about how scientific claims and information should be evaluated. This framework is used as a framework for our design (Figure 1) (Modules 2, 3). Our approach is focused on CI as part of CT to identify the source of information and assess its credibility as an essential dimension of CT in current societies. These are essential skills for improving decision-making, and promoting criticality (Module 4). Developing an integral vision of vaccination is a valuable tool for criticality and vaccine promotion. Weargue that OH is an approach that allows to raise awareness about different factors that affect vaccination and provides a better understanding of vaccine hesitancy. This deeper understanding of the current situation offers the chance to tackle the problem of vaccine hesitancy in a more integral way. Moreover, it allows us to use different skills of CT more efficiently when evaluating the problem. For instance, an OH approach will facilitate the application of CI when assessing information regarding vaccines. This step is essential for decision-making and taking action, when criticality becomes essential. The OH approach is included in Module 1. 84 Martínez-Pena et al. 10.3389/fpubh.2024.1408965 Frontiers in Public Health 04 frontiersin.org 4 Results: an instructional design for criticality on vaccination from the OH approach Our design is a 10-h training course for pre-service/in-service Secondary Education science teachers. The instruction is organized in 5 modules (1.5 h/module). It is a flexible instruction that can beadapted to the initial level of the participants, and be scheduled according to participants’ availability. It seeks to provide efficient ways to introduce OH and Criticality to promote vaccination in science lessons. Table1 provides an overview of the design and highlights the main dimension (OH, CI, or Criticality) addressed in each module. The OH approach underlies the whole design, as the global perspective of the problem provided by OH is necessary to properly put in practice CI and Criticality. The workflow of this design was elaborated considering the main abilities needed in different moments of information management FIGURE1 Reasoning workflow for decision-making during vaccine information evaluation [based on Osborne and Pimentel (31)]. 85 Martínez-Pena et al. 10.3389/fpubh.2024.1408965 Frontiers in Public Health 05 frontiersin.org that lead to decision-making and taking actions. Firstly, developing a wide and complex understanding of the problem is desirable. This is addressed in Module 1 where OH can bea beneficial approach to this purpose. Afterwards, this multi-step process involves managing information efficiently where CI plays a central role and that is tackled in Modules 2 and 3. The previous steps would lead to decision-making and developing actions to face the problem, when Criticality gains prominence. 4.1 Module 1: how can weraise awareness on vaccination? This module includes a brainstorming and one activity to help participants understand the role of vaccines in public health and the consequences of low-vaccination coverage. Its main goal is to introduce the OH approach in connection with the problem of vaccination. Also, attention is on the way teachers can raise awareness among the students about the social problem of low vaccination coverage. For this, the concept of OH is introduced and explained. 4.1.1 Activity – brainstorming Pre-service teachers are asked to express their own opinion about health and vaccination. This will allow us to introduce the topic and also to identify their initial view. The following questions can beused to guide this activity: • What is health? How would you define it using your own words? • Do youthink that human health can beaffected by environmental and animal factors? • If so, how do they affect human health? 4.1.2 Activity – using the OH approach for assessing vaccination Teachers are asked to apply the OH approach to the problem of undervaccination and to represent their view in a diagram. Wesuggest presenting the problem of infectious diseases and undervaccination as a global health problem by using the OH approach. This approach puts into perspective the complexity of new infectious-disease emergence, and the preventable-disease outbreaks. This context allows to highlight the relevance of vaccination as a community tool to prevent infectious diseases. A guiding question can be used to introduce this issue. Figure2 is an example of how OH provides a global view about infectious diseases and the role of vaccination. As showed in Figure2 vaccination plays an important role in the system of interactions. Vaccinating domestic animals and human communities can potentially limit the risk of emergence of new infectious diseases, and specially protects the population from severe diseases when infection occurs. Hence, it mainly acts in the Animal-Human interactions. Additionally, human factors (Figure2, purple bubble) can also bemodified to increase vaccination. At this level, vaccine education will raise awareness about the importance of a high vaccine coverage as a community “shield” against infectious diseases. Secondly, a group discussion will beperformed. Participants are asked to explain their OH approach to the rest of the group. All models are discussed among the whole group to enrich the learning. Both activities show the utility of the OH approach, and provide participants with ways to introduce the OH in their lessons. At the end of this module it would beexpected that teachers improve their ability to: • Foster OH regarding vaccination among students. • Raise awareness about the risks of low vaccination rates among students. TABLE1 Overview of the course for secondary education teacher instruction “How can Ipromote vaccination from a systemic, critical, and active perspective?” Module Topic/dimension Objective CI/OH/criticality Duration (min) 1How can weraise awareness about vaccination in science classrooms? Promoting an integral vision of global risks of undervaccination. OH 90 2How can Ihelp students to avoid vaccine fallacies? (I): Looking for evidence Providing tools for information management and to avoid over-information in relation to vaccines. CI 45 (II): Contrasting information 45 3 How can Iraise trust in vaccines? Developing strategies to teach about the relevance of scientific knowledge and the Nature of Science to increase trust in vaccines. CI 90 4 What can wedo to preserve public health? Learning how to orient teaching toward critical action regarding vaccination. Criticality 90 5 Propose a new design using OH approach Applying the learnt during the instruction to your own classroom and context. OH CI Criticality 90 86 Martínez-Pena et al. 10.3389/fpubh.2024.1408965 Frontiers in Public Health 06 frontiersin.org • Emphasize the importance of vaccination for maintaining a good global health status among students. 4.2 Module 2: how can vaccine fallacies beprevented among students? (I) (II) After learning about the potential of OH to promote a systemic understanding of vaccination, participants are introduced into the second module, which is focused on promoting CI to avoid fallacies and reduce vaccine hesitancy when looking for information. This module consists of two sections that correspond to the first and second steps of the methodological approach (Figure1). To develop an opinion about vaccines, students should look for information about their utility. However, some pieces of information can bemisleading, especially in the post-truth era. Thus, teachers should provide their students with tools to manage all the information they are exposed to, and CI plays a central role at this stage. Thus, the two sections of this module are focused on different steps of putting CI during the analysis of a piece of information. 4.2.1 Part (I): looking for evidence This section includes an activity focused on assessing how to tackle the first question of the methodological approach: “Is the source of information credible?” A short overview of the process of evaluating vaccine-related information (Figure1) is performed as this is a useful way to teach students how to manage vaccine over-information and misleading information. For a better understanding of this workflow, illustrative examples that participants must solve are provided. 4.2.1.1 Activity – looking for evidence Different pieces of information obtained from different sources and/or self-elaborated (i.e., news, comments on the web, videos, scientific papers…) are provided. To answer the question “Is the source of information credible?” guiding questions are also provided (Figure3). FIGURE2 Illustrative example of the relevance of vaccination to prevent the emergence of infectious diseases from the One Health approach. 87 Martínez-Pena et al. 10.3389/fpubh.2024.1408965 Frontiers in Public Health 07 frontiersin.org Note that this is adapted to the level of expertise expected from the participants (pre-service/in-service Secondary Education teachers with a biology/nature sciences/biomedical degree, or similar). However, guiding questions can beapplied to any piece of vaccine information and to different levels of expertise of students (Figure3), and so does the rest of the following activities. At the end of this section, it would be expected teachers to improve their ability to: • Help students to look for evidence when evaluating a piece of information to avoid vaccine fallacies. 4.2.2 Part (II): contrasting information Participants will assess the second question included in the design (Figure1) “Does the source have the expertise in vaccines to support its claims?.” This section includes an activity focused on the expertise of the source/author of a piece of information to accept/reject a source as trustable. 4.2.2.1 Activity – is expertise a criterion for credibility? Different sources of information are provided for their analysis. Participants are required to look for additional information related to the source/author of each piece of information. The additional FIGURE3 Representative example of the material provided for activity 2 “Looking for evidence.” Panel 1 includes the piece of information (in this case, a YouTube video). Panel 2 corresponds to the guiding questions used to assess the credibility of the information source. Panel 3 represents the concluding remarks that should beextracted after analyzing the questions of panel 2. Panel 1′ is an example of a piece of information adapted for developing this activity with Secondary Education students (12–16 years old) in science lessons; screenshot image from https://www.youtube.com/ watch?v=zBkVCpbNnkU, © Kurzgesagt – In a Nutshell, used with permission. 88 Zilver et al. 10.3389/fpubh.2024.1415548 Frontiers in Public Health 02 frontiersin.org Additionally, the societal perspective needs to be addressed. Besides the aforementioned themes, general counselling should focus on misperceptions of vaccine safety and the role of misinformation which are also important in the non-pregnant population. This study underlines the importance of including pregnant individuals in research programs to obtain specific information targeted to their needs. KEYWORDS pregnancy, pregnant individuals, COVID-19, vaccine hesitancy, SARS-CoV-2 1 Introduction The COVID-19 pandemic has an enormous global impact, and therefore is different from other recent infectious disease outbreaks (1–3). Disease burden, social isolation and distancing, loss of work, mental health problems and economic implications were unique in intensity, abruptness and severity and many of these still continue to have an effect on society. Vaccines against the virus that causes COVID-19, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), were developed in a very fast and novel manner, enabling protection against the sequelae of an infection with the virus, especially the mRNA vaccines. More than 70% of the general population accepted the vaccine (4). During the pandemic, pregnant individuals were more hesitant to receive a vaccination compared to the general population (5–8). This is particularly important, since pregnant individuals were more vulnerable to complications from COVID-19. Although severe COVID-19 is uncommon, compared to non-pregnant individuals, pregnant individuals showed higher rates of intensive care unit (ICU) admission, invasive ventilation, extracorporeal membrane oxygenation (ECMO) and higher mortality rates (9). Furthermore, pregnant individuals with severe COVID-19 have higher rates of iatrogenic preterm birth, leading to higher rates of neonatal intensive care unit (NICU) admissions (10). When comparing pregnant individuals with COVID-19 to pregnant individuals without COVID-19, severe neonatal complications are higher in pregnant individuals with COVID-19 (11). Fajardo-Martinez etal. found neurodevelopmental delay in children age 5–30 months who were exposed to maternal Sars-CoV-2 in utero (12). Initially, in 2020, pregnant individuals were excluded from phase 2 and 3 COVID-19 vaccine trials, due to safety regulations (13). However, in several countries, e.g., in the USA, pregnant individuals were able to receive the vaccine (14). As a result, data on the safety and effectivity of the vaccine became rapidly available. These data and data from individuals who inadvertently became pregnant during the COVID-19 vaccine clinical trials showed similar immunogenicity for pregnant individuals compared to non-pregnant individuals (15) and no specific risks, including side effects or adverse birth outcomes (16, 17). This resulted, at first, in an advice for pregnant individuals with underlying medical health conditions or an occupation with high risk of contact with SARS-CoV-2, to get vaccinated (18). When more data became available, the (international) advice changed from vaccination for this selection of pregnant individuals to vaccination of all pregnant individuals (19). In Netherlands, pregnant individuals were advised to receive a mRNA vaccine (Pfizer BioNTech BNT162b2 and Moderna mRNA-1273). Additionally latter data showed maternal COVID-19 vaccination was associated with lower risk of COVID-19 related hospitalization in infants <6 months of age (20). However, pregnant individuals remained hesitant to receive a COVID-19 vaccine (21); with an estimated acceptance percentage of 49% worldwide (4, 22). Vaccine hesitancy has been defined as “a delay or refusal of vaccination despite the availability.” There are several determinants that influence vaccine hesitancy which vary across time, between diseases, vaccines and communities (23). To investigate what determinants are of influence, two commonly used models are available to explain vaccine hesitancy. The first model is the 3 C’s model, comprising of complacency, convenience and confidence (23). Within this model, complacency is the perceived notion that the risk of vaccine-preventable disease is low and therefore vaccination is not a necessary preventive measure. Convenience comprehends factors such as geographical accessibility, affordability, physical availability and the ability to understand in terms of health literacy. Confidence is defined as trust in the safety and effectiveness of vaccines and the system that delivers them. This includes the competence of health care workers providing the vaccine. The Health Believe Model (HBM) is another concept that is used to explore and explain the rationale behind vaccine hesitancy, as it is a widely used to predict health behaviour (24). The HBM relies on self-efficacy in explaining health behaviour and perceived susceptibility, severity, benefits, and barriers. The HBM is based on the hypothesis that the response to a health threat is determined by a person’s perceived severity of the threat and susceptibility to the threat. Engaging in health protective behaviour is determined by the estimated benefits of the protective behaviour and potential barriers against the behaviour. Predictors of COVID-19 vaccine acceptance in pregnant individuals among different studies include: advanced maternal age, occupational status (employed individuals were more likely to receive vaccination), higher educational level, white race, having a previous influenza vaccination, third trimester of pregnancy, comorbidities, knowledge about COVID-19 (25–28). During the COVID-19 pandemic, an additional and unaddressed issue possibly contributing to vaccine hesitancy in pregnant individuals was physician hesitancy to recommend the vaccine to pregnant individuals (29). Due to the unique challenges and changes during the COVID-19 pandemic, wehypothesize that different and perhaps unique factors can beidentified in the decision-making process regarding vaccination against COVID-19 during pregnancy. This knowledge is important in the perspective of upcoming diseases and necessity of newly developed vaccines (30, 31). Therefore, the aim of this qualitative study is to explore barriers and facilitators for individuals in their decision regarding vaccination against a new virus, COVID-19, during pregnancy. The results of this 95 Zilver et al. 10.3389/fpubh.2024.1415548 Frontiers in Public Health 03 frontiersin.org study help to provide insight into which specific information will help pregnant individuals to make an informed decision about using newly developed vaccines and facilitates implementation of new vaccines in the near future during pregnancy. 2 Materials and methods 2.1 Design We conducted a qualitative study of lived experiences of pregnant individuals regarding the decision-making process for vaccination against COVID-19. A qualitative design was chosen as weaimed to gain a comprehensive understanding of the barriers and facilitators that pregnant individuals encounter in the decision-making process. Semi-structured interviews were conducted that took a narrative approach. Wehypothesized that pregnant individuals perspectives on vaccination are fuelled by their personal experiences and opinions, but also interact with the society surrounding them (32). A thematic analysis was chosen to analyse the data, as this methodology fits within the constructionist paradigm and holds space for an inquiry in the reality of participants. 2.2 Research team A multidisciplinary research team ensured variety in perspectives. The research team included three gynaecologists, a psychiatrist, a gynaecologist in training and two PhD candidates in the field of pregnancy, mental health and COVID-19. 2.3 Setting and recruitment of participants Pregnant individuals who received prenatal care in a tertiary care centre, Amsterdam University Medical Centre –location VUmc (Amsterdam UMC – VUmc) and low-risk pregnant individuals in midwifery practices in the Amsterdam area were asked to participate in the study. Purposive sampling was conducted to obtain a sample of pregnant individuals from diverse backgrounds including variations in maternal age, parity, country of birth, educational level and vaccination status. Pregnant individuals ≥18 years and with sufficient knowledge of the Dutch or English language were found eligible to participate in the study. Eligible individuals were initially approached by their health care professional and subsequently by the first author (SJMZ), to beinformed about the study. Participants received an information letter, including an informed consent form. After informed consent was obtained, an interview date was scheduled. Participants could withdraw consent at any time. Participants were allowed to bring a support person to the interview. Interviews were scheduled until no new themes emerged from the data. 2.4 Data collection All data were collected between October 2021 and January 2022 (see Figure1, timeline of lockdowns, vaccination availability and study period). During a four-month period, semi-structured interviews took place by phone, video call or onsite at the Amsterdam UMC, depending on the preference of the participant. Onsite interviews were conducted in a private consultation room within the hospital’s outpatient clinic. The space was furnished with a desk, two chairs, and a small side table with informational pamphlets. This location was chosen to create a secure, calm environment for the participant. Despite the clinical setting, efforts were made to make the participant feel comfortable, with the interviewer offering drinks and explaining the purpose of the interview clearly at the outset. The choice of a hospital setting was intended and in consultation with the participant to make it convenient for the participant, who was already visiting the clinic for an appointment. Interviews lasted between 25 and 45 min and were conducted by the first author (SJMZ). All interviews were audio-recorded. The self-developed interview guide (see Appendix 1) included a short list of background and general questions. To address the thoughts and ideas regarding vaccination and in particular COVID-19 vaccination, the interview started exploring subjects such as; general ideas on vaccination, prior vaccinations, thoughts about COVID-19in general, experiences with COVID-19, sources of information on COVID-19, opinions of healthcare providers, relatives and friends on the subject of COVID-19 vaccination. Depending on the answers, more in-depth questions were asked to elaborate on the previous answers. The study design and reporting adhered to Consolidated Criteria for Reporting Qualitative research (COREQ). FIGURE1 Timeline of lockdowns, start of vaccination and study period in Netherlands. 96 Zilver et al. 10.3389/fpubh.2024.1415548 Frontiers in Public Health 04 frontiersin.org TABLE1 Background characteristics of the participants. Participants (N= 9) Age (mean, SD) 34.8 (3.8) Country of birth Belgium 1 Bulgaria 1 India 1 Morocco 1 Netherlands 4 Suriname 1 Educational level Secondary vocational education 3 Higher professional education 3 University education 3 Marital status Single 0 Living apart together 1 Living together 5 Married 3 Previous treatment for psychological distress Yes 4 No 4 Unknown 1 Parity Primipara 2 Multipara 7 Gestational age in weeks (mean, SD) 32.4 (6.2) Gestation First trimester 0 Second trimester 3 Third trimester 6 Prenatal care Hospital 8 Midwifery practice 1 Previous COVID-19 (self-reported) Yes 6 No 2 Unknown 1 Vaccinated against COVID-19 Yes 5 No 4 The bold values state the background characteristics. 2.5 Data-analysis Interviews were recorded and transcribed ad verbatim, followed by coding according to the principles of thematic analysis (33) using the qualitative analysis software MAX QDA. The analysis included a process of familiarizing with the data (by reading and rereading transcripts), coding and interpretation. Initially, open coding of all transcripts was performed by the first author (SJMZ). To enrich the variety of codes and to complement each other’s coding, two interviews were also coded by the second author (ALR) and three by the third author (NNS). Subsequently, interpretive coding was conducted by the research team in a group meeting offering diverse perspectives to enhance reliability. Themes were constructed from the selective codes as weextracted patterns of shared meaning from the data. The transcripts and findings were not returned to the participants for member checking. 2.6 Ethical considerations The Medical Ethics Review Committee of VU University Medical Centre examined the study protocol (2021.0245). Official approval was not required. The protocol was in accordance with Dutch privacy regulations. 3 Results A total of nine pregnant individuals participated in the study. During the recruitment period of the study, eight individuals declined to participate in the study, six of these individuals were not vaccinated. Their main reason for not participating was unwillingness to discuss the topic. The other two individuals were vaccinated and did not give a particular reason for not wanting to participate in the study. Out of the nine interviews, one interview was conducted in English. Participant characteristics are shown in Table1. Maternal age ranged from 28 to 40 years. Most of the participants were multiparous and had received care at the Amsterdam UMC. None of the interviewed individuals were in their first trimester, gestation ranged from 22 to 39 weeks. After analyses, three main themes, related to decision-making regarding vaccination in pregnancy, were identified: (1) Health consequences, (2) Ambiguity of information, and (3) Societal motivation. Themes and subthemes are described in Table 2. Translated quotes support the themes. In addition, Table3 shows the themes with the main explanations in vaccinated versus unvaccinated pregnant women. 3.1 Health consequences Participants particularly expressed the importance of health for their unborn child. The unknown consequences of vaccination for their offspring were a main concern. This led to insecurities regarding the safety of vaccination versus the importance of vaccination, and also to insecurity versus confidence in their own health. 3.1.1 Insecurity versus confidence in importance of vaccination The majority of the participants recalled that prior to their pregnancy they were more open to receipt of a vaccine. However, 97 Zilver et al. 10.3389/fpubh.2024.1415548 Frontiers in Public Health 05 frontiersin.org participants perceived pregnancy to have a “special status”. This status concerns responsibility for the safety of the unborn child resulting in being extra careful with dietary restrictions and taking medication and, in addition, reluctance towards vaccination. “Yes, 100%. If Ihad not been pregnant, Iwould have taken it immediately” (P2). “Especially because during pregnancy youtry really hard and do your best not to eat certain foods, take a lot of vitamins, youtake all these things into consideration, and then youtake a vaccine of which youdo not know the long-term effects, this causes mixed feelings” (P1). 3.1.2 Insecurity versus confidence in own health Perceived physical health is an important theme but differs among participants. Some participants perceived their health as good and therefore were reluctant to choose vaccination. “Because basically, Isee myself as a healthy person” (P9). Interestingly, another participant described the opposite. Explaining that the physical disability she already felt from being (heavily) pregnant made her unsure of what would happen if she would get a COVID-19 infection as well. “Because now Ireally noticed that my breathing is high and shallow, and standing up, Iimmediately felt dizzy and out of breath, and Ifelt shortness of breath at night when Iwoke up. If this is how Ifeel just because of the pregnancy, then Ido not think it will beokay if Ihave that (COVID-19) on top” (P4). Other participants described having experienced COVID-19in the past without severe symptoms being one of the reasons not the choose vaccination. As described above, vulnerability of health during pregnancy was an important theme. Whether or not that vulnerability was a reason for vaccination, differed between participants. One participant described that she felt like her immune system was weaker and she was not sure if she wanted to receive a second vaccination during pregnancy, due to fear of feeling ill from the side effects of vaccination instead of from COVID-19 infection. “Because Ifeel that my immunity is now a bit lower. Iamafraid that those side effects from a possible second dose are more intense, and that Iwill get sick of that” (P4). 3.1.3 Consequences for offspring One of the items that was repeatedly mentioned during the interviews was not being able to know if there would beany adverse long-term effects of vaccination, in particular for their offspring. Some participants specifically expressed a fear for birth defects and longterm effects regarding for example infertility or attention disorders in their offspring. “[…]I was only allowed an mRNA vaccination, but the long-term effects are just not known and of course you have those diethylstilbesterol (DES) children and the Softenon and youhave more things that happened in the past with medication that turned out not to besuch a good idea in the longer term, Ijust did not dare to take this” (P7). “Yes, Ifind that hard to say. […]. Ifind it difficult if my child turns 30 and wants to have children of its own and then it turns out heor she is less fertile. Ido not believe my child will come out with 5 arms, or that sort of thing, but maybe he or she will have an attention deficit disorder or something like that, and that that could belinked to the vaccine. Iwould find that very difficult” (P1). 3.1.4 Consequences of illness Another factor that influenced decision-making regarding COVID-19 vaccination are personal experiences. Some participants described how they felt when they had COVID-19. “No, Ijust had a little muscle ache, just like when Ihave flu. Other than that, Ihave had no complaints” (P9). TABLE2 Overview of themes and subthemes. Themes Subthemes Health consequences • Insecurity versus convinced of importance of vaccination • Insecurity versus confidence in own health • Consequences for offspring • Consequences of illness Ambiguity of information • Information provision • Trust versus scepticism Societal motivation • Altruism • External motivation/government rules and restrictions TABLE3 Main themes with associated factors in vaccinated versus unvaccinated women. Vaccinated pregnant individuals (n= 5) Unvaccinated pregnant individuals (n= 4) Health consequences ▪ Insecurity regarding own health during pregnancy and additional risks of COVID-19 infection ▪ Unknown consequences for offspring Ambiguity of information ▪ Trust in information from health care providers/family ▪ Sceptical about scarce research (at the time) ▪ Ambiguous information provision, with advise changing from not vaccinating pregnant individuals to routinely vaccinating pregnant individuals Societal motivation ▪ Unable to live a “normal” daily life ▪ Not being able to travel without vaccination ▪ Feeling defensive, due to negative comments from society but this strengthened their own decision 98 Zilver et al. 10.3389/fpubh.2024.1415548 Frontiers in Public Health 06 frontiersin.org “Well it was not pleasant, it was hard, but luckily Iwas at home. Idid not have to go to the hospital. But Ihad to cough a lot and Ihave never been this sick in my life. Let me put it this way, it was much more than a flu” (P5). Other participants described having family or friends who had COVID-19 without any severe symptoms or hospital admission. One participant shared that she had lost a family member due to complications of a COVID-19 infection and another participant described how someone she knew had delivered a baby while she had a COVID-19 infection and the aftermath of the infection. “She really did not have enough oxygen to push and she was between life and death. After she gave birth, she also walked through her house with an oxygen tank and a baby on the other arm for months” (P7). 3.2 Ambiguity of information A second theme focuses on the relation between information provision and decision-making regarding vaccination. In general, participants found it important that information is provided in a clear and concise way. Information was available from health care providers and through different platforms, such as television, newspapers, online and social media. Participants were having difficulties to determine which information was reliable. 3.2.1 Information provision Several participants have pointed out the difficulty of the vaccination advice changing over time from not (routinely) vaccinating pregnant women due to lack of data about the safety during pregnancy, to the advice of vaccinating all pregnant women. “The conversations were overall good, the funny thing was, that people who got pregnant at the same time as me, were also advised not to get vaccinated […]. But after the government advised everybody to get vaccinated, people who have gotten pregnant since follow that advice” (P1). In addition, participants searched for information online, ranging from scientific websites to news websites and to national vaccination advisory boards. Multiple participants expressed that information on social media did not influence their decision, because they did not take this information platform seriously. “Through the internet, but Itry to seek scientific articles, not Wikipedia or a pregnant person’s personal blog. Ialso looked for simple things such as: how long has the vaccine been used, how many years has it been tested, in which countries, all those sorts of things” (P1). 3.2.2 Trust versus scepticism Despite the fact that participants felt the decision regarding vaccination was a decision they had to make on their own, some participants were influenced by opinions from people around them, including relatives and health care professionals. One participant pointed out that her midwife advised against vaccination. Another participant with multiple relatives working in the medical field, trusted their opinion when they explained that vaccination is recommended based on conducted research. “I discussed it with my family, because they are all doctors. Two GP’s and a neurologist and they said yes, go ahead, it’s safe. Wehave already seen a lot of studies, Iwould definitely recommend it” (P4). Another participant described how the combination of research, media, her partner and his colleagues made her change her mind regarding vaccination. “Yes, sure, because at first Idid not want it […]. Until at one point, the news reported that pregnant women were at high risk, especially towards the end of the last trimester. Your belly is bigger and youhave less lung capacity, so the chance is higher that you end up in the ICU. […] I thought: oh, Iwill soon beheavily pregnant in the winter, during the cold and flu season. […] Colleagues of my husband that are doctors also said: all pregnant women weknow, including doctors, had the vaccination themselves. Then Ithought: Ijust have no choice, vaccination is probably safer than Ithink. The risk of the longer term does not outweigh the actual risk for me and the child that may have to bedelivered early if Iget COVID” (P2). One participant was sceptical about the research on which the advice to routinely vaccinate all pregnant women was based on. Another participant explained that she became more doubtful when she came across links on websites that asked her to participate in research regarding COVID-19 vaccination during pregnancy. To her it was a confirmation that vaccination for COVID-19 was still subject of research. “At first it is discouraged and then strongly recommended after a study in America […]” (P5). “Especially when Iwas on the website of the National Institute for Public Health and the Environment (RIVM), links of pregnant women kept popping up: participate in a study so wecan see what the vaccine does, and Iunderstand 100%, Ifully understand that it is something very normal that this is being investigated. Only with me personally, Ido not know, it made me doubt even more, that Ithought: oh yes, see, they actually still have to investigate this” (P2). 3.3 Societal motivation The third theme relates to societal motivation and influences to the decision-making process regarding COVID-19 vaccination. Most of the participants spoke about different ways in which COVID-19 influenced society. Participants also reported different ways in which society influenced the decision-making process regarding vaccination. For some participants altruism played a role in the decision to receive vaccination against COVID-19, for other participants external motivation due to additional rules and restrictions for people who were not vaccinated made them decide to get the vaccination. 99 Zilver et al. 10.3389/fpubh.2024.1415548 Frontiers in Public Health 07 frontiersin.org 3.3.1 Altruism Some participants felt an obligation to consider the consequences for the whole society, in particular vulnerable people and therefore decided to receive vaccination. “[…] Ihave not had the feeling that Ihave to protect myself that much, but […] Ijust think it is important that as many people as possible get vaccinated in order to prevent this and Iwanted to contribute to that myself, so that has been the reason that Ijust had to get vaccinated” (P8). 3.3.2 External motivation As previously described, some participants initially did not want to receive vaccination because they were not particularly concerned for their own health and were bothered by the unknown long-term effects. However, due to the Dutch government rules, some participants changed their mind. Requiring a negative COVID-19 test prior to visiting public facilities if not vaccinated was a logistic challenge for participants, especially with a newborn. In addition, the risk of social isolation also provided a new reason to choose vaccination. “I thought, if the little one is here, and Iamup on my feet again, Icannot go anywhere during the winter months, then Iwould feel very isolated. […]. So now Ireceived my first vaccination two weeks ago and Iamgoing to get the second one next week and then Ihave a QR code once the baby is here. This is due to the rules that are in place right now […] Ifelt forced, that sounds heavy, but that is kind of what happened” (P1). International travel restrictions were also a potential factor influencing the decision. Some of the participants were not originally born in Netherlands and without vaccination unable to visit family in other countries. “For example Morocco, my parents live there, so if Iwant to visit my parents, I have to receive the vaccination, because it is mandatory if youwant to go there” (P6). One participant described how she felt judged by society and government for her choice not to vaccinate during pregnancy. “My vulnerability, so to speak, was completely put aside, as if Idid it because Iwant to bedifficult, as if Iama crazy person, it does not matter how you want to call it, but you are not seen nor acknowledged that the position as a pregnant woman is difficult, even aside from all the other factors. Ifound that very intense” (P7). 4 Discussion 4.1 Main findings In this study weexplored the barriers and facilitators for pregnant individuals choice and motivation regarding vaccination against COVID-19 during pregnancy in Netherlands. We found three themes that capture the perspectives of pregnant individuals regarding vaccination against COVID-19: health consequences, ambiguity of information and societal motivation. Health consequences referred to their own health, but also the health and possible consequences for their offspring. Lack of long-term data and therefore uncertainty on possible adverse long-term effects for their offspring, were a main point of concern. In addition, unambiguous information provision based on evidence, with regard to why pregnant individuals were advised to receive vaccination, is an important topic that needs to beaddressed. Not only for health care providers, but also for policy makers, national health institutes and societies for maternal and foetal medicine. Furthermore, provided information should also match individuals specific ideas, feelings and perceptions regarding vaccination and in addition take life experiences into account. The unique restrictions resulting from COVID-19 being a pandemic, added societal motivation as a reason for vaccination. Without vaccination there were restrictions to traveling and entering public places. From the societal point of view, altruism was also important and resulted in deciding to get vaccination to protect vulnerable people in society. The three main themes, health consequences, ambiguity of information and societal motivation, indicate that pregnant individuals perspectives for vaccination are shaped by personal experiences and interactions with the broader societal context. 4.2 Interpretation of findings Literature has provided numerous models to explain decisionmaking in healthcare. In comparison to the 3C model wefound that confidence and complacency aligned with the findings from our study. Wefound a confidence barrier due to safety concern of the vaccine and a complacency barrier regarding not being convinced that contracting a COVID-19 infection negatively impacts their lives. However, our study did not show any convenience barriers, instead wefound convenience facilitators such as being able to travel abroad after vaccination and avoiding having to take a COVID test prior to entering public places. Furthermore, the Health Believe Model (HBM) that is used to explore and explain the rationale behind vaccine hesitancy, also provides similarities to our findings (24, 34). The HBM is based on the hypothesis that the response to a health problem is determined by a persons perceived severity of the threat and the individual perceived susceptibility to the threat. Both of these themes, perceived severity and susceptibility to COVID-19 were also seen in our study. However, in addition to HBM two noteworthy considerations specific for pregnant individuals were identified in our study: (1) the responsibility for their unborn child and (2) the vulnerability to complications from a COVID-19 infection due to the pregnancy. Although some similarities between our findings and both models are evident, these models do not acknowledge the profound influence of society on individuals decision-making regarding vaccination. A model that would better fit this part of our findings is a conceptual framework of social values in health priority settings, showing the principal of solidarity, described in a few different ways, such as; decisions which give priority to those who are worst-off in health terms which is similar to altruism in our study (35). In addition, the World Health Organization Strategic Advisory Group of Experts on Immunization (SAGE) working group on vaccine hesitancy describes the complex determinants of vaccine hesitancy in three categories: (1) contextual influences, (2) individual and group influences, and (3) vaccine-specific issues (36). 100 [Document text truncated for crawler view.]