Edi ed by
G aça S. Ca alho and Ca los Albe o De Oli ei a Magalhães Júnio
Published in
F on ie s in Public Heal h
Vaccine educa ion and
p omo ion
May 2025
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ISSN 1664-8714
ISBN 978-2-8325-6337-3
DOI 10.3389/978-2-8325-6337-3
May 2025
F on ie s in Public Heal h 2 on ie sin.o g
Vaccine educa ion and p omo ion
Topic edi o s
G aça S. Ca alho — Uni e si y o Minho, Po ugal
Ca los Albe o De Oli ei a Magalhães Júnio — S a e Uni e si y o Ma ingá, B azil
Ci a ion
Ca alho, G. S., Júnio , C. A. D. O. M., eds. (2025). Vaccine educa ion and
p omo ion. Lausanne: F on ie s Media SA. doi: 10.3389/978-2-8325-6337-3
May 2025
F on ie s in Public Heal h 3 on ie sin.o g
07 Edi o ial: Vaccine educa ion and p omo ion
G aça S. Ca alho and Ca los Albe o de Oli ei a Magalhães Júnio
11 “Le ’s ge back o no mal”: emo ions media e he e ec s o
pe suasi e messages on willingness o accina e o
COVID-19
K is a R. Muis, Panayio a Kendeou, Ma ina Koha su and
Shu ing Wang
23 Vaccine communica ion s a egies among heal hca e
wo ke s as a e lec ion o he Is aeli Minis y o Heal h’s
communica ion s a egies be o e and a e he COVID-19
pandemic
Rana Hijazi, Ana Gesse -Edelsbu g and Gus a o S. Mesch
34 De e minan s o in luenza non- accina ion among Canadian
child en: insigh s om a na ionwide su ey
Abdallah Alami, Sailly Da e, Ca en Uhlik, Ma wa Eb ahim,
Daniel K ewski and Julie La oche
47 Spa io empo al analysis o HPV accina ion and associa ed
neighbo hood-le el dispa i ies in Texas—an ecological s udy
Ryan Ramphul, Abigail S. Zamo ano, Saswa i Upadhyay, Manali Desai
and Cici Baue
55 De e minan s o pneumococcal accina ion d opou among
child en aged 12–23 mon hs in E hiopia: a seconda y analysis
om he 2019 mini demog aphic and heal h su ey
Ayenew Asse a, Teklehaimano Ki os, Mula E kihun,
Aynewo k Abebaw, Ayenew Be han and Anda gachew Almaw
63 Explo ing he ela ionship be ween accine hesi ancy and
mo he s’ pe spec i es on COVID-19 accines o child en
ages 5–11 yea s du ing he omic on p edominan pe iod
2021–2022: a quali a i e s udy
Ti any A. Su agh, Da id Adz ago, Ma lyn A. Allicock, Paul G. Yeh and
Paula Cucca o
72 Communi y Heal h Volun ee s’ expe iences o implemen ing
COVID-19 accine educa ion and p omo ion in Kenya: a
quali a i e desc ip i e s udy
Cons ance S. Shumba, Pe e son Ki ai he, Isabel Kambo and
Sheila Shaibu
82 One Heal h educa ion o c i icali y on accina ion in eache
aining
Inés Ma ínez-Pena, Blanca Puig and A ai z Uskola
94 P egnan indi iduals pe spec i es owa ds ecei ing
COVID-19 accina ion du ing hei p egnancy: an in-dep h
quali a i e s udy
Sanne J. M. Zil e , Anna L. Rie eld, No alie N. Schonewille,
Pe a C. A. M. Bakke , Bi i F. P. B oekman, Elisabe h an Leeuwen and
Ch is ianne J. M. de G oo
Table o
con en s
May 2025
F on ie s in Public Heal h 4 on ie sin.o g
104 In es iga ing he in luencing ac o s o accina ion decisions
o newly de eloped and es ablished accines: a compa a i e
s udy based on la en class logi models in China
Shiyun Chang, Biao Xu, Hailing Xi and Yi an Shao
117 Co igendum: In es iga ing he in luencing ac o s o
accina ion decisions o newly-de eloped and es ablished
accines: a compa a i e s udy based on la en class logi
models in China
Shiyun Chang, Biao Xu, Hailing Xi and Yi an Shao
118 Unde s anding he pes zos e accine hesi ancy and
in o ma ion asymme y: a quali a i e s udy in China
Xiaolong Wang, Yu ei Xing, Enming Zhang, Zhengyue Dai, Yuan Li,
Shuhui Shang, Jiale Hu, Xian Zhang and Qiong Fang
129 Awa eness o HPV and HPV accine among college s uden s
in China
Manman Li, Fengzhi Zhang, Yun Shi, Kaige Shi, Xiaoxue Li and Hua Bai
136 Role o communi y engagemen in ad ancing accine equi y
Saman ha Smi h, E ika Ma quez, Amanda Haboush-Deloye, Tiana Tu,
Aaliyah Goodie and Da id Pe ez
144 Connec ing he expe iences o pe sons wi h disabili ies and
social wo ke s in Nige ian ca e ins i u ions ega ding
COVID-19 accine up ake: a quali a i e
desc ip i e-in e p e i e design
Fa ah Naz Rahman, An hony Obinna Iwuagwu,
Ch is ophe Ndubuisi Ngwu, Michael Ebe Kalu, Amani Kashe wa,
Mohammad Rocky Khan Chowdhu y and Manzu Kade
157 Up ake and co ela es o in luenza accine among olde
adul s esiding in u al egions o sou h China: a
c oss-sec ional s udy
Peizhen Zhao, Wenqian Xu, Jinshen Wang, Peng Liang, Haiyi Li and
Cheng Wang
166 In o ma ion needed o op imal immuniza ion ela ed o
medical ad ice: an obse a ional p ospec i e coho s udy
p o ocol (INFORMed)
Jenni e W enge , Be ina Be ge , Da id D. Ma in and
Ekkeha Jene zky
173 Can social media p omo e accina ion? S a egies and
e ec i eness o COVID-19 accine popula iza ion on
Chinese Weibo
Jing Xu, Di an Guo, Jing Wu and Jinghong Xu
182 Unde s anding s uden engagemen in accina ion
educa ion: an in e iew-based mul i-s akeholde s udy
Melissa Schlopsna and Anne e Schee soi
May 2025
F on ie s in Public Heal h 5 on ie sin.o g
198 Vaccina ion: a look a he social ep esen a ions o B azilian
child en
Suelen de Gaspi, Ca los Albe o de Oli ei a Magalhães Júnio ,
Rosa B anca T acana, Edua da Ma ia Schneide and G aça S. Ca alho
206 Lessons lea ned om he COVID-19 pandemic: iden i ying
hesi an g oups and explo ing easons o accina ion
hesi ancy, om adolescence o la e adul hood
Lau e Pauly, Ca oline Resido i, Hamid Bulu , Dmi y Bulae ,
Soumyab a a Ghosh, Ma c P. O’Sulli an, Joëlle V. F i z,
Michel Vaillan , Basile Rommes, Robin Samuel, Venka a P. Sa agopam,
Rejko K üge and Anja K. Leis on behal o he CON-VINCE
Conso ium and he ORCHESTRA Wo king G oup
220 Examining psychological co ela es o accine hesi ancy: a
compa a i e s udy be ween he US and Is ael
Nicolle Simono ic, Ana Gesse -Edelsbu g and Jenni e M. Tabe
231 Explo ing ac o s in luencing childhood immuniza ion s a us
in Eas A ica using mul ile el o dinal logis ic eg ession
analysis
As e Addisu Di es, Demeke Lakew Wo kie and Abay Kassa Teklie
242 The in luence o ac o s ela ed o public heal h campaigns
on accina ion beha io among popula ion o Wuxi egion,
China
Yang Ye and Anselm Ting Su
257 F om class ooms o eal-wo ld con ex s: enhancing accine
educa ion h ough open schooling
Hannah Kwella, Jana Schilbe , Amélie Tessa z and
Anne e Schee soi
269 Heal h belie model o pa en s’ COVID-19 accina ion
in en ions o child en: pe cei ed bene i s and ba ie s in
Indonesia
Eka Wu i Handayani, Dyah A yani Pe wi asa i and
F ed ick De mawan Pu ba
277 Analysis o ac o s in luencing HPV accina ion in en ion
among Chinese college s uden s: s uc u al equa ion
modeling based on heal h belie heo y
Shi-Yuan Song, Ying Guo, Yi-Hua Li, Zheng Wang and Wei Gao
295 Sociodemog aphic dispa i ies in in luenza accina ion among
olde adul s in Uni ed S a es
Huan Tao, Jin Chen, Xue Zhang, Tao Wang, Nenggang Jiang and
Yongqian Jia
May 2025
F on ie s in Public Heal h 6 on ie sin.o g
303 Communi y-engaged cu iculum de elopmen using acial
jus ice and biomedical lenses o add ess COVID-19 accine
hesi ancy in black indi iduals wi h heuma ologic condi ions
Eseosa Oli e Osaghae, G e a Si ek, Tonya Robe son, Mia Chandle ,
A iel Childs, Monica C espo-Bosque, Gina Cu y, Ama Dhand,
Ma y Dollea , Alice Eggels on, Nnenna Ezeh, Dieu o Fleu issain ,
Denice Ga e , Gail G an ille, Mu iel Jean-Jacques, Elena Losina,
Holly Milaege , Lu iyya Muhammad, Ma y Ann Nelson,
Chisa Nosamie an, Bisola Ojiku u, Neil Pillai, Ma y Be h Son,
Ma ie Jacques Toussain , Ana Valle, Jessica N. Williams, Michael Yo k,
Ka en Mance a-Cue as, Candace H. Feldman and
Rosalind Ramsey-Goldman
312 Compa a i e analysis o he ole o heal hca e belie s on
childhood accina ion up ake among pa en s in Malaysia and
Singapo e du ing he COVID-19 pandemic
Jia Ming Low, E win Jiayuan Khoo, Meow Keong Thong, Chloe Soo,
Anh Phuong T an, Le Ye Lee and Fook Choe Cheah
TYPE Edi o ial
PUBLISHED 29 Ap il 2025
DOI 10.3389/ pubh.2025.1610968
OPEN ACCESS
EDITED AND REVIEWED BY
Ch is iane S ock,
Ins i u e o Heal h and Nu sing
Science, Ge many
*CORRESPONDENCE
G aça S. Ca alho
[email p o ec ed]
RECEIVED 13 Ap il 2025
ACCEPTED 14 Ap il 2025
PUBLISHED 29 Ap il 2025
CITATION
Ca alho GS and J´
unio CAdOM (2025)
Edi o ial: Vaccine educa ion and p omo ion.
F on . Public Heal h 13:1610968.
doi: 10.3389/ pubh.2025.1610968
COPYRIGHT
©2025 Ca alho and J´
unio . This is an
open-access a icle dis ibu ed unde he
e ms o he C ea i e Commons A ibu ion
License (CC BY). The use, dis ibu ion o
ep oduc ion in o he o ums is pe mi ed,
p o ided he o iginal au ho (s) and he
copy igh owne (s) a e c edi ed and ha he
o iginal publica ion in his jou nal is ci ed, in
acco dance wi h accep ed academic p ac ice.
No use, dis ibu ion o ep oduc ion is
pe mi ed which does no comply wi h hese
e ms.
Edi o ial: Vaccine educa ion and
p omo ion
G aça S. Ca alho1*and
Ca los Albe o de Oli ei a Magalh˜
aes J´
unio 2
1Resea ch Cen e o Child S udies, Uni e si y o Minho, B aga, Po ugal, 2S a e Uni e si y o Ma ingá,
Ma ingá, PR, B azil
KEYWORDS
de e minan s o accina ion, accina ion hesi ancy, accina ion among s uden s, heal h
educa ion, heal h p omo ion
Edi o ial on he Resea ch Topic
Vaccine educa ion and p omo ion
This edi o ial highligh s key de elopmen s in he Public Heal h Resea ch Topic
“Vaccine educa ion and p omo ion.” This c i ical a ea aims o in o m and encou age
accina ion by p o iding accu a e scien i ic in o ma ion and implemen ing e ec i e
accina ion p og ams, emphasizing hei bene i s, sa e y, and ole in p e en ing in ec ious
diseases. A o al o 39 manusc ip s we e submi ed o conside a ion. Following a igo ous
pee - e iew p ocess and e isions based on expe eedback, 29 (74.3%) we e accep ed
o publica ion. Among hese, 14 explo e he de e minan s o accina ion, eigh examine
accine hesi ancy and se en add ess accina ion among s uden s.
1 De e minan s o accina ion
The de e minan s o accina ion a e di e se bu can be b oadly ca ego ized in o
h ee g oups (1): (i) Con ex ual ac o s, including his o ical, socio-cul u al, en i onmen al,
heal h sys em/ins i u ional, economic, and poli ical in luences; (ii) Indi idual and g oup
in luences, such as pe cep ions o accines and he impac o social o pee en i onmen s;
(iii) Vaccine- and accina ion-speci ic Resea ch Topic, ac o s di ec ly ela ed o he
accine o he ac o accina ion i sel . Vaccina ion up ake also a ies ac oss isk
popula ions, wi h dis inc de e minan s po en ially in luencing beha io in each g oup
(2). As such, a ho ough unde s anding o hese ac o s is essen ial o designing a ge ed
in e en ions o imp o e immuniza ion co e age (3). The 13 pape s included in his
sec ion, De e minan s o Vaccina ion, a e o ganized ac oss h ee Resea ch Topic:
1.1 Se en pape s look a communica ion and engagemen
o accina ion
Chang e al. compa ed USA public accina ion decisions o newly-de eloped and
es ablished accines, and ecognized he need o clea communica ion and communi y
engagemen as c i ical s a egies o add essing public conce ns and misin o ma ion;
F on ie s in Public Heal h 01 on ie sin.o g
7
Ca alho and J´
unio 10.3389/ pubh.2025.1610968
Rahman e al. looked a he pe cep ions o Nige ian pe sons wi h
disabili ies ega ding he COVID-19 pandemic and he accine
and iden i ied he need o cul u ally and eligiously sensi i e
communica ion s a egies, and ailo ed educa ional p og ams by
social wo ke s; Xu e al. analyzed “ accine science popula iza ion”
in he Chinese social media Weibo du ing he COVID-19 pandemic
whe e publishe s we e di ided in o indi iduals, o ganiza ions,
media, go e nmen , and scien is s, and e i ied ha Weibo
scien is s’ a gumen s we e hose ha mo e posi i ely in luenced he
e ec o accine popula iza ion; Hijazi e al. iden i ied he Is aeli
Minis y o Heal h communica ion s a egies ega ding accines
du ing COVID-19 pandemic and how heal hca e wo ke s shaped
hei p o essional socializa ion p ocesses wi hin he heal h sys em,
leading o a eliance on es ablished communica ion s a egies
and in o ma ional channels; Shumba e al. analyzed communi y
heal h olun ee s expe iences o implemen ing COVID-19 Vaccine
educa ion and p omo ion in Kenya du ing he pandemic, showing
hey con ibu ed o he high up ake o p ima y accines and
boos e s; W enge e al. used a p o ocol (INFORMed) in Ge many
o iden i y he wish o ad ice in hesi an and no-hesi an
new-bo n’s pa en s and he compa ison o pa en s in e ms o
hei espec i e in o ma ion needs; and Smi h e al. add essed a
communi y engagemen amewo k ha can p o ide a oadmap
o na iga e he dynamic and mul i ace ed na u e o equi y- ela ed
wo k by pa ing he way o meaning ul in e en ions o mi iga e
heal h dispa i ies.
1.2 Fou pape s look a socioeconomics
disc epancy
Tao e al. ound subs an ial acial and socioeconomic dispa i ies
in in luenza accina ion up ake among Uni ed S a es adul s
aged 65 yea s o olde ; Zhao e al. in es iga ed he ex en o
in luenza accine co e age in sou h China adul s aged 60 yea s
o olde and iden i ied he ac o s in luencing accine up ake;
Ramphul e al. iden i ied a eas in Texas, USA, wi h high and low
HPV accina ion a es and explo ed di e ences in neighbo hood
cha ac e is ics, showing ha accina ion co e age a es depend on
he communi y’s income le el; and Ye and Ting Su explo ed he
ac o s ela ed o public heal h campaigns, in Wuxi egion o China,
ha can imp o e accina ion a es in low socioeconomic g oups
and u al a eas, o con ibu ing o be e public heal h s a egies.
1.3 Th ee pape s look a child en’s
immuniza ion
Alami e al. analyzed he Canadian su ey abou
pa en s/gua dians’ pe spec i es on in luenza immuniza ion
and iden i ied he main ac o s in luencing low a es o child en’s
accina ion, such as esiding in u al a eas, lowe pa en al
educa ion and lowe household income; Di es e al. looked a
he ac o s in luencing childhood immuniza ion s a us in Eas
A ica, which a ied among coun ies and egions, and ound ha
mo he s a ending an ena al ca e played a key ole in child en’s
accina ion; and Asse a e al. e alua ed he de e minan s o
pneumonia conjuga e accine (PCV) d opou among child en
aged 12–23 mon hs in E hiopia and iden i ied he signi ican
ac o s in luencing PCV d opou , such as ha ing a heal h ca d,
ha ing ecei ed he PCV 2 accina ions, and egion.
2 Vaccina ion hesi ancy
Vaccine hesi ancy e e s o he delay in accep ance o ou igh
e usal o accines despi e he a ailabili y o accina ion se ices; i
is a complex and con ex -speci ic phenomenon ha a ies ac oss
ime, loca ion, and ype o accine (4). I has been linked o
declining accina ion co e age and a heigh ened isk o ou b eaks
and epidemics o accine-p e en able diseases (5). The eigh pape s
in he Vaccina ion Hesi ancy sec ion a e dis ibu ed ac oss wo
Resea ch Topic:
2.1 Fi e pape s add ess accina ion
hesi ancy in he communi y
Osaghae e al. le e aged long-s anding communi y-
academic pa ne ships in wo ci ies o de elop a cu iculum
o in e en ions o dec ease COVID-19 accine hesi ancy
wi hin Black communi ies in he USA; Muis e al. examined he
e ec i eness o h ee di e en messages o pe suading Canadian
indi iduals o ge accina ed agains COVID-19, and he ole ha
emo ions play in pe suasion, e i ying ha emo ions media ed
ela ions be ween accine con idence/hesi ancy and willingness;
Pauly e al. iden i ied COVID-19 accine hesi an g oups om
adolescence o la e adul hood and explo ed hei mo i a ions
o and agains accina ion in a na ionwide Luxembou gish
popula ion, being he accina ion hesi ancy highe in he younge
age g oups; Zil e e al. s udied ba ie s and acili a o s o
Ne he lande p egnan women’s choice and mo i a ion ega ding
accina ion agains COVID-19 du ing p egnancy, e i ying
ha hey needed clea , unambiguous in o ma ion conce ning
heal h consequences, pa icula ly o hei o sp ing; and Wang
e al. conduc ed a quali a i e su ey using Vaccine Hesi ancy
De e minan s Ma ix and 5C model o unde s and and imp o e
He pes zos e accina ion a es among middle-aged and olde
adul s in China.
2.2 Th ee pape s add ess pa en s’
accina ion hesi ancy
Low e al. in es iga ed pa en s’ accine hesi ancy a es in
Malaysia and Singapo e, and explo ed whe he hese a es we e
associa ed wi h pa en s’ heal h belie s, ha ing ound ha he
p e alence o pe cei ed pa en al accine hesi ancy was highe
in Malaysia; Handayani e al. conduc ed a s udy in Indonesia
aiming o de elop guidance o in-dep h in e iews o a u u e
quali a i e s udy based on a c oss-sec ional quan i a i e s udy o
pa en s wi h school-age child en and ound a signi ican associa ion
be ween pa en s’ in en ion o accina e hei child en and he
pe cei ed bene i s and pe cei ed ba ie s o accina ion; and
Su agh e al. conduc ed a s udy on accine hesi ancy among
USA whi e pa en s wi h highe educa ion and socioeconomic
F on ie s in Public Heal h 02 on ie sin.o g
8
Muis e al. 10.3389/ pubh.2024.1377973
F on ie s in Public Heal h 05 on ie sin.o g
he accine con idence subscale was 0.86, and 0.73 o he accine
hesi ancy subscale.
Expe imen al ex s
Th ee expe imen al ex s we e de eloped based on con en om
he Cen e s o Disease Con ol websi e on COVID-19 accina ions.1
Excep o he pe sonal message componen , all ea u es o he ex s
we e iden ical (e.g., used pe suasi e language, he same c edible
sou ces, and w i en o bepe sonally ele an ). The i s 68 wo ds we e
he same ac oss all h ee ex s, which began by p o iding basic
in o ma ion abou COVID-19 and s a ing how con agious COVID-19
is. The ex s hen desc ibed i as a se ious h ea and ecommended
ha he h ea should be aken se iously o p e en u he sp ead. The
ex s hen p esen ed in o ma ion wi h ega ds o accines, hei sa e y
and e icacy, and hen p o ided encou agemen o ge accina ed.
The key di e ences be ween he h ee ex s we e mino wo ding
ha ocused on p o ec ing onesel (sel -in e es ), p o ec ing onesel
and o he s (sel -in e es + al uis ic), o p o ec ing onesel and o he s
as well as ge ing back o a no mal li e (sel -in e es + al uis ic +
no mal). Fo example, o he ex ha ocused on p o ec ing onesel ,
ollowing he in o ma ion on how con agious he i us is, he ex
s a ed, “This means COVID-19 is a se ious h ea o you,” whe eas he
o he wo ex s s a ed, “This means COVID-19 is a se ious h ea o
youand you communi y.” As ano he example, he ex ha ocused
on pe sonal p o ec ion s a ed, “COVID-19 accina ion helps p o ec
you om ge ing sick o se e ely ill wi h COVID-19” whe eas he
o he wo ex s s a ed, “COVID-19 accina ion will help p o ec you
om ge ing sick o se e ely ill wi h COVID-19 and will help p o ec
you lo ed ones and he people a ound you. Tha is, e en i youdo ge
COVID-19 a e being accina ed, i may also p e en you om
sp eading i o o he s.” Finally, o he ex ha ocused on ge ing back
o no mal, he ex added he ollowing, “People who ha e been ully
accina ed can s a o do some hings ha hey had s opped doing
because o he pandemic. Coun ies like he UK and Is ael a e ge ing
back o hei no mal li e because e e yone is doing hei pa and
ge ing accina ed. To s op his pandemic, e e yone will need o ge
accina ed. This is he only way wewill beable o ge back o a no mal
li e. P o ec you sel and o he s om COVID-19. Le ’s ge back o
no mal!” All ex s hen ended wi h “Do no wai . Vaccina e!” and we e
ollowed by a pamphle ha highligh ed he main message (i.e.,
p o ec onesel ; p o ec onesel and o he s; p o ec onesel and o he s,
and le ’s ge back o no mal). See Appendix A o he ex s and
pamphle s. To al wo d coun o he ex s we e 172, 224, and 298,
espec i ely, wi h a Flesch eading ease sco e o 46.3, and a Flesch–
Kincaid g ade le el o 9.9 o all h ee ex s.
Emo ions
A sel - epo ques ionnai e consis ing o i e i ems was used o
measu e pa icipan s’ emo ions owa d COVID-19 accines. Each
i em consis ed o a single wo d (e.g., “Happy”) and pa icipan s we e
asked o epo he in ensi y o hei emo ional esponse o COVID-19
accines (con ol condi ion) a e hey ead he ex ( ex condi ions).
Single-i em measu es ha e demons a ed o be psychome ically
sound subs i u es o mul i-i em scales when adminis a ion ime is
1 h ps://www.cdc.go /co ona i us/2019-nco / accines/index.h ml
sho [e.g., (52)]. In ensi y was epo ed using a 5-poin Like scale
using he ollowing labels: No a all (1), Ve y li le (2), Mode a e (3),
S ong (4), and Ve y S ong (5). The i e emo ions included: joy, hope,
empa hy, elie , and ange .
Willingness o ge a COVID-19 accine
A se en-i em measu e was de eloped o assess pa icipan s’
willingness o ge a COVID-19 accine (e.g., “In ligh o he
COVID-19 ou b eak, Iamwilling o…”). Pa icipan s we e asked o
a e hei willingness using a sliding a ing scale ha anged om 0
“No a all willing o do his” o 100 “Ve y willing o do his,” wi h 50
“Mode a ely willing o do his” as he middle ma ke . The i s i em
assessed gene al willingness o ge a COVID-19 accine (e.g., “Ge a
COVID-19 accine”), along wi h mo e speci ic op ions including
choice o accine (e.g., “Ge a COVID-19 accine i Ican choose
which one Ige ”), no choice (e.g., “Ge a COVID-19 accine e en i
Icanno choose which one Ige ”), and hen willingness o ge a
speci ic accine cu en ly a ailable in Canada (e.g., “Ge he P ize /
Mode na/As aZeneca/Johnson and Johnson accine o COVID-
19”). Ch onbach’s alpha eliabili y o he se en-i em scale was 0.90.
Demog aphic in o ma ion
Pa icipan s epo ed hei age, sex, i s language spoken, highes
le el o educa ion comple ed, cu en heal h s a us ( anging om poo
o excellen ), wha heal h issues hey ha e, how equen ly hey ge he
lu accine, cu en employmen s a us, essen ial wo ke s a us,
ma i al s a us, annual income, esidence loca ion (e.g., pos al code;
u ban, subu ban, o u al a ea, e c), numbe o pa en s/child en/
indi iduals li ing wi h hem, poli ical a ilia ion, s eng h o poli ical
a ilia ion o social issues, s eng h o poli ical a ilia ion o economic
issues, ime spen pe day ollowing in o ma ion abou COVID-19,
sou ces o ha in o ma ion (e.g., CBC, Facebook, Fox News, Radio-
Canada, CNN), and eligiosi y (e.g., eligious a ilia ion and s eng h
o belie s).
P ocedu e
A e ob aining e hics app o al om he Resea ch E hics Boa d
(REB), pa icipan s we e ec ui ed h ough MTu k and ia a snowball
sampling echnique h ough social media (Facebook). A link was
p o ided o Qual ics (on MTu k and Facebook, housed by ou
uni e si y o ensu e enc yp ed p ocedu es we e s ic ly ollowed),
which was he pla o m used o collec ing da a. Pa icipan s names
we e no collec ed o ensu e anonymi y and all in o ma ion was s o ed
on a secu e, locked compu e wi h double au hen ica ion measu es o
ensu e con iden iali y. Only he i s au ho had access o he da a,
which was all in nume ical o m. Pa icipan s i s consen ed, a e
which hey comple ed he accine con idence and hesi ancy
ques ionnai e. Pa icipan s we e hen andomly assigned o one o
ou condi ions: p o ec you sel “sel -in e es ” condi ion; p o ec
you sel and o he s “sel -in e es + al uis ic” condi ion; p o ec
you sel , o he s, and le ’s ge back o no mal “sel -in e es + al uis ic
+ no mal” condi ion; o he con ol condi ion (no pe suasi e message).
A e eading (o no in he case o he con ol condi ion),
pa icipan s epo ed hei emo ions abou COVID-19 accines
ollowed by hei willingness o ge a COVID-19 accine. Pa icipan s
hen comple ed he demog aphics ques ionnai e a e which hey we e
15
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F on ie s in Public Heal h 06 on ie sin.o g
paid o hei ime (MTu k) o we e en e ed in o a d aw o win $100
(wi h a chance o winning being 1in 50). To been e ed in o he d aw,
pa icipan s ec ui ed h ough Facebook we e p o ided he i s
au ho ’s email and we e asked o con ac he i s au ho wi h a
andomly gene a ed code p o ided a he end o he su ey.
Pa icipan s in he con ol condi ion spen app oxima ely 10 min
comple ing he su ey, whe eas pa icipan s in he ex condi ions
spen app oxima ely 12 min (sel -in e es ) o 13 min (sel -in e es +
al uis ic, and sel -in e es + al uis ic + no mal) comple ing he
su ey and eading he ex s.
Resul s
P elimina y da a sc eening and analyses
P io o conduc ing analyses, i was i s necessa y o check o
no mali y and ou lie s, and whe he g oups di e ed on conce n,
accine con idence, and accine hesi ancy. As expec ed, mos a iables
we e skewed due o he na u e o he i ems, which is common in
esea ch on accine hesi ancy and in esea ch on emo ions [see (32)].
Mo eo e , as expec ed, he e we e no di e ences be ween g oups on
conce n abou COVID-19, F(3, 325) = 1.08, p > 0.05, accine
con idence, F(3, 325) = 2.19, p > 0.05, o accine hesi ancy, F(3,
325) = 1.23, p > 0.05. Table1 epo s means and s anda d de ia ions o
willingness o ge accina ed and emo ions as a unc ion o condi ion,
and Table2 epo s co ela ions be ween all a iables.
Sample cha ac e is ics o accine
hesi ancy
To assess whe he ou sample o accine hesi an / esis an
indi iduals was consis en wi h p e ious li e a u e (3, 13–15), we i s
iden i ied whe he indi iduals we e hesi an / esis an o no . Based on
pa icipan s’ sco e on accine hesi ancy (i.e., an a e age sco e highe
han 3, he neu al poin on he scale), pa icipan s we e coded as
accine hesi an / esis an (23%) o accine con iden (77%).
Consis en wi h p e ious esea ch, indi iduals who we e accine
hesi an / esis an we e p ima ily emale (62%), Ca holic (25%),
mode a ely o ex emely eligious (47%), bu also iden i ied mos ly o
he Libe al Pa y o Canada (46%).
In e es ingly, he e we e no di e ences in accine hesi ancy
be ween hose sampled om MTu k and hose om Facebook
(χ2 = 2.94, d = 1, p = 0.09) and indi iduals who we e accine hesi an
did no di e in hei in o ma ion sou ces o COVID-19 om hose
who we e accine con iden . Fo bo h g oups, 22% ob ained hei
in o ma ion om CBC News ( he mos equen sou ce). Mo eo e ,
eg ession analyses e ealed ha accine hesi ancy was no p edic ed
by age (p = 0.62), heal h s a us ( anging om poo o excellen ;
p = 0.72), numbe o heal h issues (p = 0.96), le el o conce n abou he
pandemic (p = 0.21), o le el o educa ion (p = 0.40). Howe e , le el o
eligiosi y was a signi ican posi i e p edic o whe ein s onge
eligious belie s p edic ed mo e hesi ancy, β = −0.27, p < 0.001.
E ec o pe suasi e messages on
willingness o ge accina ed
To examine he i s esea ch ques ion, whe he g oups di e ed
on willingness o ge accina ed as a unc ion o ype o pe suasi e
message and hesi ancy, using conce n as a co a ia e, ANCOVA esul s
e ealed a main e ec o ex condi ion, F(3, 325) = 2.80, p = 0.04,
η2 = 0.03, a main e ec o hesi ancy g oup, F(1, 325) = 70.54, p < 0.001,
η2 = 0.18, bu no in e ac ion, F(3, 325) = 1.07, p > 0.05. As hypo hesized,
indi iduals who we e con iden in accines we e mo e willing o ge
accina ed han hose who we e hesi an / esis an (Hypo hesis 3).
Follow-up pos hoc analyses using LSD e ealed ha indi iduals
in he sel -in e es + al uis ic + no mal condi ion we e mo e
willing o ge accina ed compa ed o he con ol condi ion
TABLE1 Means and s anda d de ia ions o willingness o ge accina ed and emo ions as a unc ion o ex condi ion and hesi ancy.
Con ol (n = 86) Sel -in e es (n = 76) Sel -in e es +
Al uis ic (n = 84)
Pe sonal + Al uis ic +
No mal (n = 79)
Vaccine con iden
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)
Empa hy 2.75 (1.26) 3.13 (1.29) 3.00 (1.26) 2.84 (1.40)
Relie 3.27 (1.21) 3.93 (0.99) 3.67 (1.10) 3.87 (1.02)
Ange 1.85 (1.03) 1.50 (0.94) 1.50 (0.89) 1.65 (0.88)
Vaccine hesi an /Resis an
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)
Empa hy 2.70 (1.45) 2.40 (1.18) 2.94 (1.47) 2.43 (1.50)
Relie 2.62 (1.13) 2.73 (0.96) 2.94 (1.29) 3.43 (0.96)
Ange 2.29 (1.26) 2.46 (1.18) 2.29 (1.35) 2.18 (1.10)
S anda d de ia ion is in (b acke s).
16
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F on ie s in Public Heal h 07 on ie sin.o g
(p = 0.004) and sel -in e es + al uis ic condi ion (p = 0.004)
(Hypo hesis 1). Howe e , coun e o ou hypo hesis, he e we e no
di e ences in willingness be ween he sel -in e es + al uis ic +
no mal condi ion and he sel -in e es condi ion. Simila ly,
indi iduals in he sel -in e es condi ion we e mo e willing o ge
accina ed compa ed o indi iduals in he sel -in e es + al uis ic
condi ion (p = 0.02) and con ol condi ion (p = 0.02) (Hypo hesis 2).
Finally, coun e o ou hypo hesis, indi iduals in he sel -in e es +
al uis ic condi ion did no di e on willingness compa ed o he
con ol condi ion (p > 0.05).
We u he explo ed whe he accine ype ma e ed, and whe he
choice o no choice as o which accine indi iduals ecei ed ma e ed
wi h ega d o messaging and willingness. Indeed, despi e la ge
di e ences in willingness ac oss he a ious accines (pa icula ly
high willingness o P ize and Mode na, bu low o As azeneca and
Johnson and Johnson), he same pa e ns o esul s we e eplica ed,
wi h much highe willingness o ge accina ed (upwa d o 20%) when
indi iduals we e gi en he choice o which accine o ecei e
compa ed o when hey we e no gi en a choice.
E ec o pe suasi e ex s on emo ions
Fo he second esea ch ques ion, whe he emo ions di e ed as a
unc ion o ex condi ion and hesi ancy, o joy, ANCOVA esul s
e ealed a signi ican main e ec o ex condi ion, F(3, 325) = 7.92,
p < 0.001, η2 = 0.07, a main e ec o hesi ancy g oup, F(1, 325) = 33.23,
p < 0.001, η
2
= 0.10, bu no in e ac ion, F(3, 325) = 1.63, p > 0.05. As
hypo hesized, indi iduals who we e accine con iden exp essed mo e
joy in ela ion o he COVID-19 accine compa ed o indi iduals who
we e accine hesi an / esis an (Hypo hesis 5). Pos hoc ollow-up
analyses using LSD e ealed ha , as hypo hesized, indi iduals in he
sel -in e es + al uis ic + no mal condi ion exp essed signi ican ly
mo e joy abou he COVID-19 accine compa ed o indi iduals in he
o he h ee condi ions (all p < 0.01). Indi iduals in he sel -in e es and
sel -in e es + al uis ic condi ions also exp essed signi ican ly g ea e
joy han hose in he con ol condi ion (bo h ps < 0.01), and no
di e ences we e ound in joy be ween indi iduals in he sel -in e es ed
condi ion and he sel -in e es ed + al uis ic condi ion (Hypo hesis 4).
Fo hope, ANCOVA esul s e ealed a signi ican main e ec o
ex condi ion, F(3, 325) = 4.73, p = 0.003, η
2
= 0.04, a main e ec o
hesi ancy g oup, F(1, 325) = 35.67, p < 0.001, η
2
= 0.10, bu no
in e ac ion, F(3, 325) = 1.27, p > 0.05. As hypo hesized, indi iduals
who we e accine hesi an / esis an we e less hope ul abou he
accine han hose who we e accine con iden . Pos hoc ollow-up
analyses using LSD e ealed ha he e we e no di e ences be ween
he h ee pe suasi e ex condi ions on hope, bu ha indi iduals in
all ex condi ions we e signi ican ly mo e hope ul han indi iduals in
he con ol condi ion (all p < 0.001).
Fo empa hy, ANCOVA esul s e ealed no signi ican e ec s o
in e ac ions (all p > 0.05). Fo elie , ANCOVA esul s e ealed a
signi ican main e ec o ex condi ion, F(3, 325) = 4.16, p = 0.007,
η2 = 0.04, a main e ec o hesi ancy g oup, F(1, 325) = 25.95, p < 0.001,
η2 = 0.08, bu no in e ac ion, F(3, 325) = 1.08, p > 0.05. As hypo hesized,
indi iduals who we e accine hesi an / esis an we e less elie ed
abou he accine han hose who we e accine con iden . Pos hoc
ollow-up analyses using LSD e ealed ha he e we e no di e ences
be ween he h ee pe suasi e ex condi ions on elie , bu ha
indi iduals in all ex condi ions we e signi ican ly mo e elie ed han
indi iduals in he con ol condi ion (all p < 0.001). Finally, o ange ,
ANCOVA esul s e ealed no main e ec o ex condi ion,
F(3, 325) = 0.37, p > 0.05, bu a main e ec o hesi ancy g oup,
F(1, 325) = 24.63, p < 0.001, η
2
= 0.07, and no in e ac ion,
F(3, 325) = 0.76, p > 0.05. As hypo hesized, indi iduals who we e
accine hesi an / esis an we e mo e ang y abou he accine han
hose who we e accine con iden .
Rela ions be ween accine con idence,
hesi ancy, emo ions, and willingness o ge
accina ed
To answe he las esea ch ques ion ega ding ela ions be ween
accine con idence, hesi ancy, emo ions, and willingness o ge
accina ed, a pa h analysis using Mplus (53) was conduc ed (Figu e1).
The model e ealed an excellen i , χ
2
= 28.13, d = 3, p < 0.001,
CFI = 0.96, RMSEA = 0.06 (Figu e2). Vaccine con idence nega i ely
p edic ed ange (β = −0.38, p < 0.001) and posi i ely p edic ed joy
(β = 0.41, p < 0.001), hope (β = 0.53, p < 0.001), elie (β = 0.32,
p < 0.001), p < 0.001, empa hy (β = 0.14, p = 0.004) and willingness o
ge accina ed (β = 0.59, p < 0.001). In con as , accine hesi ancy
posi i ely p edic ed ange (β = 0.44, p < 0.001) and empa hy (β = 0.14,
p < 0.001), bu nega i ely p edic ed joy (β = −0.38, p < 0.001), hope
(β = −0.20, p < 0.001), elie (β = −0.13, p = 0.002), and willingness o
ge accina ed (β = −0.60, p < 0.001). Joy also posi i ely p edic ed
willingness o ge accina ed (β = 0.28, p < 0.01), as did elie (β = 0.09,
p < 0.05), and empa hy (β = 0.08, p < 0.05), whe eas ange nega i ely
p edic ed willingness o accina ed (β = −0.21, p < 0.001). Media ion
TABLE2 Ze o-o de co ela ions be ween a iables.
Hesi ancy Joy Hope Empa hy Relie Ange Willingness
Con idence −0.500** 0.56** 0.567** 0.306** 0.603** −0.277** 0.625**
Hesi ancy −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**
Empa hy 0.277** −0.065 0.222**
Relie −0.406** 0.512**
Ange −0.254**
**Signi ican a p < 0.001. *Signi ican a p < 0.05.
17
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F on ie s in Public Heal h 08 on ie sin.o g
analyses u he e ealed ha ange (−0.08, p < 0.001) and elie (0.03,
p = 0.04) media ed ela ions be ween accine con idence and
willingness, whe eas ange (0.09, p < 0.001) and empa hy (0.02,
p = 0.04) media ed ela ions be ween accine hesi ancy and
willingness. Wediscuss hese esul s nex .
Discussion
The pu pose o his s udy was o examine he e ec s o h ee
di e en ypes o pe suasi e messages on willingness o ge accina ed
o COVID-19. Wealso explo ed he ole ha emo ions play in social
pe suasion o be e unde s and he mechanisms unde lying social
pe suasion ia ex -based messages. Resul s e ealed ha consis en
wi h hypo heses, he ex ha ocused on ge ing back o no mal in
addi ion o p o ec ing onesel and o he s (sel -in e es + al uis ic +
no mal) was mo e e ec i e in pe suading indi iduals o ge accina ed
compa ed o he con ol condi ion (no message) and he sel -in e es
+ al uis ic condi ion. Howe e , he e we e no di e ences in
willingness o ge accina ed be ween he sel -in e es + al uis ic +
no mal condi ion and he sel -in e es condi ion, and no di e ences
be ween he con ol condi ion and he sel -in e es +
al uis ic condi ion.
The inding ha he sel -in e es + al uis ic condi ion did no
a ec willingness o ge accina ed is coun e o ecen esea ch ha
ound ha sel -in e es + al uis ic pe suasi e messages we e mo e
e ec i e in inc easing indi iduals’ beha io al in en ions like social
dis ancing/beha io s and wea ing masks compa ed o no pe suasi e
message (10–12). A guably, such social beha io s may becons ued
as ela i ely easy o engage in o p o ec o he s compa ed o ge ing
accina ed, pa icula ly o hose indi iduals who a e accine hesi an /
esis an . As such, a message ha ocuses on p o ec ing o he s may no
be an e ec i e way o encou age indi iduals o ge accina ed.
Howe e , he pe suasi e message abou p o ec ing onesel was jus as
e ec i e in inc easing indi iduals’ willingness o ge accina ed
compa ed o he message ha ocused on ge ing back o no mal,
which also had an al uis ic componen o i , bu only o indi iduals
who we e no accine esis an . To explain hese esul s, welooked
deepe in o he e ec s o each o he messages as a unc ion o
indi iduals’ hesi ancy owa d accines.
Vaccine hesi ancy and pe suasion
A close examina ion o he e ec s o each ype o message as a
unc ion o accine hesi ancy g oup (see Table1) shows ha o
accine hesi an indi iduals, he only message ha inc eased
willingness o ge accina ed was “Le ’s ge back o no mal.” Gi en ha
he o he wo pe suasi e ex condi ions had means lowe han he
con ol condi ion o indi iduals who we e accine hesi an , and ha
he “no mal” condi ion inc eased willingness by o e 10% compa ed
o he con ol condi ion, wein e p e his esul as meaning ul and
impo an om a public messaging pe spec i e. In he con ex o
pandemic a igue (2), o pe suade accine hesi an / esis an
indi iduals o ge accina ed may equi e a ocus on ge ing li e back
o no mal wi h ega ds o he emo al o es ic ions and egaining o
indi idual eedoms.
Fo accine con iden indi iduals, bo h he sel -in e es condi ion
and he sel -in e es + al uis ic + no mal condi ion inc eased
willingness o ge accina ed by 10% abo e he con ol condi ion.
These esul s sugges ha in he con ex o a pandemic, indi iduals
who a e con iden in accines a e willing o p o ec hemsel es bu a e
also wan ing o ge li e back o no mal. I may be he case ha
indi iduals we e mo e d i en o p e en hemsel es om ge ing
se iously sick o dying han hey we e o p o ec ing o he s om
ge ing sick. Al e na i ely, a he ime ha accines we e olling ou , i
was no clea whe he o o wha ex en he COVID-19 accines
dec eased i al load o sp ead o he i us and, as such, he message
o p o ec o he s may no ha e been con incing o indi iduals since
in o ma ion was apidly changing a ha ime (54). Taken oge he ,
hese esul s sugges ha con ex ma e s, and ha messaging needs
o be ailo ed as a unc ion o indi iduals’ belie s abou accines and
o he psychological a iables like choice e sus no choice.
Indeed, a b ie examina ion o he his o y o he an i- accina ion
mo emen has shown ha accine hesi ancy has been a ound since
he dawn o accines [see (55)]. Fac o s ha a ec accine hesi ancy
FIGURE2
Final model.
18
Muis e al. 10.3389/ pubh.2024.1377973
F on ie s in Public Heal h 09 on ie sin.o g
include complacency (pe cei ed low isk, low gene al knowledge and
awa eness), con idence ( us in accine sa e y, he sys em o policy
make s), con enience (a ailabili y, accessibili y, a o dabili y),
calcula ion (engagemen in ga he ing ex ensi e in o ma ion), and
collec i e esponsibili y (willingness o p o ec o he s) (56).
His o ically, eligious belie s (i.e., “i is no God’s will”) and manda o y
p og ams spa ked a dis us in accines and io s due o es ic ions
on pe sonal eedoms (57, 58). Mode n-e a dis us o accines g ew
om conce ns o e accine sa e y and e icacy, pa icula ly a e he
polio accine was eleased wi h a li e, ac i e i us ha had nega i e
epe cussions o a small p opo ion o child en who we e gi en he
accine (59). Today, ac o s like eligious belie s, cul u al belie s, and
pe cep ions o isk and ha m con inue o d i e accine hesi ancy.
P io accine his o y, pe cei ed sa e y o accines, he impac s o
accine manda es, poli ical a ilia ion, in o ma ion and misin o ma ion
on he in e ne , and sa is ac ion wi h go e nmen decision-making on
o he aspec s o COVID-19 p e en ion o s a egy managemen also
played a signi ican ole in he up ake o COVID-19 accines (60).
Resul s om ou s udy p o ide u he e idence o hese ac o s
playing a ole. Tha is, indi iduals wi h s ong eligious belie s we e
mo e accine hesi an and we e mo e likely o a ilia e wi h he libe al
go e nmen o Canada, which is coun e o wha is ypically ound in
he US wi h Republicans being mo e accine hesi an (61). Wha is
pa icula ly no ewo hy wi h ou esul s is ha choice ma e ed o
indi iduals, ega dless o whe he hey we e accine con iden o
hesi an . Indeed, willingness o ge accina ed was 90% o indi iduals
in he “le ’s ge back o no mal” and “pe sonal” condi ions bu d opped
o 72% o hose same condi ions when choice o accine was
emo ed. These pe cen ages d opped o 62 and 54%, espec i ely,
when As azeneca was he op ion, e lec ing indi iduals’ dis us in
his accine gi en news o blood clo s being a isk ac o . Mo eo e , as
p e iously no ed, o accine hesi an indi iduals, willingness was
signi ican ly highe wi h he message o ge ing back o no mal han
any o he message, and his was pa icula ly p onounced when hey
had he choice o accines (82% willing) e sus when hey did no
ha e a choice (46% willing). Acco dingly, he e may ha e been some
addi i e e ec s o accine hesi an indi iduals whe e he message o
ge ing back o no mal coupled wi h a choice o accine was he mos
powe ul app oach o social pe suasion. To u he unde s and he
mechanisms in ol ed in social pe suasion, i is also impo an o
conside he ole o emo ions.
The ole o emo ions in pe suasion
Indeed, o all h ee pe suasi e message condi ions, indi iduals
el mo e joy, hope, and elie han hose in he con ol condi ion, wi h
no di e ences in le el o emo ional in ensi y o he h ee pe suasi e
message condi ions (wi h he excep ion o joy). Mo eo e , no
di e ences we e ound be ween pe suasi e ex condi ions and he
con ol condi ion o ange o empa hy. These esul s sugges ha he
pe suasi e messages had equal e ec s on inc easing hope and elie ,
ega dless o he ype o pe suasi e message, and had no e ec on
empa hy o ange . Mos impo an , o he condi ion ha included he
message o ge ing back o no mal, indi iduals exp essed he g ea es
joy compa ed o indi iduals in he o he h ee condi ions.
As p e ious empi ical wo k has demons a ed, posi i e emo ions,
like joy, can inc ease e o ul p ocessing o in o ma ion (33) and
esul in assimila ion o new in o ma ion in o cu en knowledge
s uc u es (35). As such, i appea s ha in his con ex , joy played a
signi ican ole in inc easing indi iduals’ willingness o ge accina ed,
pe haps om a belie ha hings will ge back o no mal. Indeed,
esul s om pa h analyses e ealed ha g ea e accine con idence
p edic ed mo e joy, elie , hope and empa hy and less ange , whe eas
g ea e accine hesi ancy nega i ely p edic ed joy, hope, and elie , bu
posi i ely p edic ed ange and empa hy. Mo eo e , he mo e ang y
indi iduals we e abou he accine, he less willing hey we e o ge
accina ed. Howe e , he mo e joy, hope, elie , and empa hy hey
expe ienced, he mo e willing hey we e o ge accina ed. These
emo ions also media ed ela ions be ween accine con idence and
hesi ancy whe ein o con idence, joy and elie we e posi i e
media o s whe eas ange was a nega i e media o and, o hesi ancy,
elie was a nega i e media o whe eas empa hy was a
posi i e media o .
These esul s ha e impo an implica ions o he e ec s ha
emo ions ha e on p ocessing pe suasi e in o ma ion, pa icula ly
when he message ocuses on ge ing li e back o no mal unde
pandemic ci cums ances. D awing om he emo ions li e a u e (32),
i may be he case ha p ocessing o he pe suasi e messages was
enhanced due o an inc ease in joy, hope, and elie ac oss all h ee
condi ions. These esul s sugges ha pe suasi e messages ha ocus
on ge ing back o no mal could pe suade he la ges numbe o
indi iduals o ge accina ed, pa icula ly hose who a e accine
hesi an / esis an . Al hough accine campaigns ha e a ge ed accine
sa e y and p o ec ion o onesel (sel -in e es ) and o he s (al uis ic),
an addi ional ocus on ge ing back o a no mal li e may bekey o
achie ing a high accine up ake. In he con ex o COVID-19 whe e,
in Canada, many es ic ions we e pu in o place ha limi ed
indi iduals’ eedoms (pa icula ly in he p o ince o Quebec), a ocus
on egaining hose eedoms ia accina ion and “ge ing back o
no mal” may ha e been a powe ul app oach o social pe suasion. In
o he con ex s, his “no mal” message may no ha e been e ec i e i
eedoms we e no es ic ed. As such, he e icacy o his app oach
may no ansla e o o he si ua ions whe e eedoms a e
no h ea ened.
Implica ions, limi a ions, and u u e
di ec ions
Taken oge he , esul s om his s udy ha e b oade accine
educa ion and p omo ion implica ions. Messages om us wo hy
sou ces a e impo an o inco po a e in o heal h p omo ion
messaging, along wi h a highligh o he sa e y o he accine. Gi en
he his o y o accine hesi ancy (55), manda ing accines is no a good
choice o p omo e accine up ake. Ra he , esul s om his s udy
sugges ha choice is c i ical as is a ocus on eedoms a he han he
emo al o hem. Educa ion abou he sa e y and e icacy o accines
is also c i ical (55). Bu in he con ex o apidly changing in o ma ion
abou COVID-19 and accines, his elemen o accine sa e y and
e icacy was nea ly impossible, so eedom o choice may ha e been
key. Resul s om his esea ch also sugges ha posi i e emo ional
appeals may p omp indi iduals o beless esis an o accines and
os e con idence in hei use.
F om an in o ma ion p ocessing pe spec i e (35), i may be he
case ha posi i e emo ions os e a deepe p ocessing o educa ional
19
Muis e al. 10.3389/ pubh.2024.1377973
F on ie s in Public Heal h 10 on ie sin.o g
in o ma ion abou accines. Fu u e esea ch is needed o e alua e
p ecisely how emo ions impac in o ma ion p ocessing, pa icula ly
o accine hesi an indi iduals. Fo example, a hink-emo e-aloud
p o ocol [see (62)] may bean e ec i e way o cap u e indi iduals’
emo ions and cogni i e and me acogni i e p ocesses o examine hei
in e play du ing eading o pe suasi e messages, pa icula ly o
socio-scien i ic issues like accine hesi ancy. Fu u e esea ch is also
needed ha akes in o conside a ion o he ac o s ha a ec accine
up ake like pe cei ed suscep ibili y, h ea o se e i y o illness, and
he po en ial ole o communi y engagemen . Mo eo e , ou s udy
was conduc ed in Canada, which, cul u ally, is conside ed a mo e
socialis coun y compa ed o o he s like he U.S. Wha was
su p ising o us was he inding ha “p o ec ing o he s” did no ha e
he posi i e e ec on willingness as i has in he pas in he Canadian
con ex [see (12)]. Fu u e wo k is needed o disen angle why his may
ha e been he case and whe he o he cul u es ha a e mo e o less
collec i is o socialis would espond in simila ways o “ge ing back
o no mal.”
One limi a ion o his s udy is ha wedid no include al uis ic
only o no mal only message condi ions o be e de e mine wha
speci ic aspec o he messages we e mos e ec i e in inc easing
indi iduals’ willingness o ge accina ed. A second limi a ion o his
s udy is ha wedid no measu e ac ual accine up ake. Al hough
accine in en ions a e a s ong p edic o o beha io (63), a mo e
powe ul e alua ion o he e ec i eness o ou messages would ha e
been o include a ollow-up assessmen as o whe he indi iduals go
accina ed o COVID-19 o no . Fu u e esea ch should also conside
in e iewing indi iduals o be e unde s and he e ec s o pe suasi e
messages and why indi iduals we e mo e willing (o no ) o ge
accina ed. A be e unde s anding o he unde lying mechanisms o
pe suasion will allow o imp o ed pe suasi e messages ha may
mo e e ec i ely comba accine hesi ancy and esis ance.
Da a a ailabili y s a emen
The aw da a suppo ing he conclusions o his a icle will
bemade a ailable by he au ho s, wi hou undue ese a ion.
E hics s a emen
The s udies in ol ing humans we e app o ed by Resea ch E hics
Re iew Boa d a McGill Uni e si y. The s udies we e conduc ed in
acco dance wi h he local legisla ion and ins i u ional equi emen s.
The pa icipan s p o ided hei w i en in o med consen o
pa icipa e in his s udy.
Au ho con ibu ions
KM: Concep ualiza ion, Da a cu a ion, Fo mal analysis, Funding
acquisi ion, In es iga ion, Me hodology, P ojec adminis a ion,
Resou ces, So wa e, Supe ision, Valida ion, Visualiza ion, W i ing
– o iginal d a , W i ing – e iew & edi ing. PK: Concep ualiza ion,
Me hodology, Valida ion, Visualiza ion, W i ing – e iew & edi ing.
MK: W i ing – e iew & edi ing. SW: W i ing – e iew & edi ing.
Funding
The au ho (s) decla e ha inancial suppo was ecei ed o he
esea ch, au ho ship, and/o publica ion o his a icle. Suppo o
his esea ch was p o ided by a g an o KM om he Canada
Resea ch Chai ’s P og am (G239700).
Con lic o in e es
The au ho s decla e ha he esea ch was conduc ed in he
absence o any comme cial o inancial ela ionships ha could
becons ued as a po en ial con lic o in e es .
Publishe ’s no e
All claims exp essed in his a icle a e solely hose o he au ho s
and do no necessa ily ep esen hose o hei a ilia ed o ganiza ions,
o hose o he publishe , he edi o s and he e iewe s. Any p oduc
ha may be e alua ed in his a icle, o claim ha may be made by i s
manu ac u e , is no gua an eed o endo sed by he publishe .
Supplemen a y ma e ial
The Supplemen a y ma e ial o his a icle can be ound online
a : h ps://www. on ie sin.o g/a icles/10.3389/ pubh.2024.1377973/
ull#supplemen a y-ma e ial
Re e ences
1. Pil ch-Loeb R, DiClemen e R. The accine up ake con inuum: applying social
science heo y o shi accine hesi ancy. Vaccine. (2020) 8:76. doi: 10.3390/
accines8010076
2. Wo ld Heal h O ganiza ion. Ten h ea s o global heal h. Gene a: Wo ld Heal h
O ganiza ion (2019).
3. Mu phy J, Valliè es F, Ben all RP, She lin M, McB ide O, Ha man TK, e al.
Psychological cha ac e is ics associa ed wi h COVID-19 accine hesi ancy and
esis ance in I eland and he Uni edKingdom. Na Commun. (2021) 12:29. doi: 10.1038/
s41467-020-20226-9
4. Pe y R, Cacioppo J. The elabo a ion likelihood model o pe suasion. J. Exp. Soc.
Psychol. (1986) 19:123–205. doi: 10.1016/S0065-2601(08)60214-2
5. Mu phy PK. Teaching as pe suasion: a new me apho o a new decade. Theo y
P ac . (2001) 40:224–7. doi: 10.1207/s15430421 ip4004_2
6. Muis KR, E oubashi N, Den on C. The ca che in he lie: he ole o emo ions and
epis emic judgmen s in changing s uden s’ misconcep ions and a i udes in a pos - u h
e a. Con emp Educ Psychol. (2020) 62:101898. doi: 10.1016/j.cedpsych.2020.101898
7. Thacke IE, Sina a GM, Muis KR, Danielson RW, Pek un R, Winne PH, e al. Using
pe suasi e e u a ion ex s o p omp a i udinal and concep ual change. J Educ Psychol.
(2021) 112:1085–99. doi: 10.1037/edu0000434
8. Be y TR, Wha -Higgins J, Naylo PJ. SARS wa s: an examina ion o he quan i y
and cons uc ion o heal h in o ma ion in he news media. Heal h Commun. (2007)
21:35–44. doi: 10.1080/10410230701283322
9. Jones LW, Sinclai R, Cou neya KS. The e ec s o sou ce c edibili y and message
aming on exe cise in en ions, beha iou s, and a i udes: an in eg a ion o he
elabo a ion likelihood model and P ospec heo y. J Appl Soc Psychol. (2003) 33:179–96.
doi: 10.1111/j.1559-1816.2003. b02078.x
20
Muis e al. 10.3389/ pubh.2024.1377973
F on ie s in Public Heal h 11 on ie sin.o g
10. E e e JAC, Colomba o C, Chi uc V, B ady WJ, C ocke M. The e ec i eness o
mo al messages on public heal h beha io al in en ions du ing he COVID-19 pandemic.
Psychology. (2020). doi: 10.31234/os .io/9yqs8
11. Jo dan J, Yoeli E, Rand DG. Don’ ge i o don’ sp ead i ? Compa ing sel -
in e es ed e sus p osocially amed COVID-19 p e en ion messaging. PsyA Xi .
(2020). doi: 10.31234/os .io/yuq7x
12. Muis KR, Sina a GM, Pek un R, Kendeou P, Mason L, Jacobson NG, e al.
Fla ening he COVID-19 cu e: emo ions media e he e ec s o pe suasi e message
on p e en i e ac ion. F on Psychol. (2023) 14:1148252. doi: 10.3389/
psyg.2023.1148252
13. Ellenwood R, Boyd AD, Higheagle S ong Z. Communica ion and pe spec i es
abou COVID-19 and accina ions among na i e Ame icans. Sci Commun. (2023)
45:172–94. doi: 10.1177/10755470221151184
14. Head KJ, Kas ing ML, S u m LA, Ha sock JA, Zime GD. A na ional su ey
assessing SARS-CoV-2 accina ion in en ions: implica ions o u u e public heal h
communica ion e o s. Sci Commun. (2020) 42:698–723. doi:
10.1177/1075547020960463
15. Sallam M. COVID-19 accine hesi ancy wo ldwide: a concise sys ema ic
e iew o accine accep ance a es. Vaccine. (2021) 9:160. doi: 10.3390/
accines9020160
16. T e o s G. The oles o iden i y con lic , emo ion, and h ea in lea ning om
e u a ion ex s. Soc Sci Res Ne w. (2020). doi: 10.2139/ss n.3555148
17. T e o s G, Kendeou P. The e ec s o posi i e and nega i e emo ional ex
con en on knowledge e ision. Q J Exp Psychol. (2020) 73:1326–39. doi:
10.1177/1747021820913816
18. P a heiche S, Nocku L, Böhm R, Sassen a h C, Pe e sen MB. The emo ional pa h
o ac ion: Empa hy p omo es physical dis ancing du ing he COVID-19 pandemic.
(2020). doi: 10.31234/os .io/y2cg5
19. Dole JA, Sina a GM. Reconcep ualizing change in he cogni i e cons uc ion
o knowledge. Educ Psychol. (1998) 33:109–28. doi: 10.1080/00461520.1998.9653294
20. Pe y RE, Cacioppo JT. The elabo a ion likelihood model o pe suasion In:
Communica ion and pe suasion. Be lin: Sp inge (1986). 1–24.
21. Pe y RE, P ies e JR, B iñol P. Mass media a i ude change: implica ions o he
elabo a ion likelihood model o pe suasion In: J B yan and D Zillmann, edi o s.
Media e ec s: Ad ances in heo y and esea ch. Mahwah, NJ: Law ence E lbaum
Associa es (2002). 155–89.
22. Chambliss MJ, Ga ne R. Do adul s change hei minds a e eading
pe suasi e ex ? W i Commun. (1996) 13:291–313. doi:
10.1177/0741088396013003001
23. Blankenship KL, Hol g a es T. The ole o di e en ma ke s o linguis ic
powe lessness in pe suasion. J Lang Soc Psychol. (2005) 24:3–24. doi:
10.1177/0261927X04273034
24. Ko A, Limaye RJ. Deli e ing isk in o ma ion in a dynamic in o ma ion
en i onmen : aming and au ho i a i e oice in cen e s o disease con ol (CDC)
and p ime ime b oadcas news media communica ions du ing he 2014 Ebola
ou b eak. Soc Sci Med. (2016) 169:42–9. doi: 10.1016/j.socscimed.2016.09.029
25. Flynn BS, Wo den JK, Bunn JY, Connolly SW, Do wald AL. E alua ion o
smoking p e en ion ele ision messages based on he elabo a ion likelihood model.
Heal h Educ Res. (2011) 26:976–87. doi: 10.1093/he /cy 082
26. Pe y RE, B iñol P, Teeny J, Ho cajo J. The Elabo a ion Likelihood Model:
Changing a i udes owa d exe cising and beyond. In B. Jackson, J. A. Dimmock and J.
Comp on (Eds.), Pe suasion and communica ion in spo , exe cise, and physical ac i i y.
Rou ledge. (2017), 22–37.
27. Be sch C, Böhm R, Ko n L, Hol mann C. On he bene i s o explaining he d
immuni y in accine ad ocacy. Na Hum Beha . (2017) 1:1–6. doi: 10.1038/
s41562-017-0056
28. Li M, Taylo EG, A kins KE, Chapman GB, Gal ani AP. S imula ing in luenza
accina ion ia p osocial mo i es. PLoS One. (2016) 11:780. doi: 10.1371/jou nal.
pone.0159780
29. Pek un R, Linnenb ink-Ga cia L. In e na ional handbook o emo ions in
educa ion. London: Rou ledge (2014).
30. Sina a GM, Sey anian V. Wa m change abou ho opics: he ole o mo i a ion
and emo ion in a i ude and concep ual change abou con o e sial science opics
In: L Co no and EM Ande man, edi o s. Handbook o educa ional psychology. New
Yo k: Rou ledge/Taylo & F ancis G oup (2016). 245–56.
31. Sche e KR, Moo s A. The emo ion p ocess: e en app aisal and componen
di e en ia ion. Annu Re Psychol. (2019) 70:719–45. doi: 10.1146/annu e -
psych-122216-011854
32. Pek un R, S ephens EJ. Academic emo ions In: KR Ha is, S G aham, T U dan,
JM Roye and M Zeidne , edi o s. APA educa ional psychology handbook, Vol 2:
Indi idual di e ences and cul u al and con ex ual ac o s. Washing on, DC:
Ame ican Psychological Associa ion (2012). 3–31.
33. Muis KR, Pek un R, Sina a GM, Aze edo R, T e o s G, Meie E, e al. The
cu ious case o clima e change: es ing a heo e ical model o epis emic belie s,
epis emic emo ions, and complex lea ning. Lea n Ins . (2015) 39:168–83. doi:
10.1016/j.lea nins uc.2015.06.003
34. Meinha d J, Pek un R. A en ional esou ce alloca ion o emo ional e en s: an
ERP s udy. Cogni Emo . (2003) 17:477–500. doi: 10.1080/02699930244000039
35. Bohn-Ge le CM. Ge ing a g ip: he PET amewo k o s udying how eade
emo ions in luence comp ehension. Discou se P ocess. (2019) 56:386–401. doi:
10.1080/0163853X.2019.1611174
36. T e o s GJ. The oles o iden i y con lic , emo ion, and h ea in lea ning om
e u a ion ex s on accina ion and immig a ion. Discou se P ocesses. (2021)
59:1–16. doi: 10.1080/0163853X.2021.1917950
37. T e o s G, Bohn-Ge le C, Kendeou P. The e ec s o expe imen ally induced
emo ions on e ising common accine misconcep ions. Q J Exp Psychol. (2021)
74:1966–80. doi: 10.1177/17470218211017840
38. G egoi e M. Is i a challenge o a h ea ? A dual-p ocess model o eache s'
cogni ion and app aisal p ocesses du ing concep ual change. Educ Psychol Re .
(2003) 15:147–79. doi: 10.1023/A:1023477131081
39. T e o s G, Kendeou P, Bu e uss R. Emo ions in knowledge e ision. Discou se
P ocess. (2017) 54:406–26. doi: 10.1080/0163853X.2017.1312201
40. Muis KR, Che ie M, Singh CA. The ole o epis emic emo ions in pe sonal
epis emology and sel - egula ed lea ning. Educ Psychol. (2018) 53:165–84. doi:
10.1080/00461520.2017.1421465
41. Xue J, Chen J, Hu R, Chen C, Zheng C, Su Y, e al. Twi e discussions and
emo ions abou he COVID-19 pandemic: machine lea ning app oach. J Med
In e ne Res. (2020) 22:e20550. doi: 10.2196/20550
42. He ne J, Vi es ML, Feldman Hall O. Emo ional esponses o p osocial
messages inc ease willingness o sel -isola e du ing he COVID-19 pandemic. Pe s
Indi id Di . (2021) 170:110420. doi: 10.1016/j.paid.2020.110420
43. Diekema DS. Rhe o ic, pe suasion, compulsion, and he s ubbo n p oblem
o accine hesi ancy. Pe spec Biol Med. (2022) 65:106–23. doi: 10.1353/
pbm.2022.0006
44. Huang Y, G een MC. Reducing COVID-19 accine hesi ancy among A ican
Ame icans: he e ec s o na a i es, cha ac e ’s sel -pe suasion, and us in science.
J Beha Med. (2022) 46:290–302. doi: 10.1007/s10865-022-00303-8
45. Liu S, Yang JZ, Chu H. When weinc ease ea , do wedampen hope? Using
na a i e pe suasion o p omo e human papilloma i us accina ion in China. J
Heal h Psychol. (2021) 26:1999–2009. doi: 10.1177/1359105319894626
46. Faul F, E d elde E, Lang AG, Buchne A. G* powe 3: a lexible s a is ical
powe analysis p og am o he social, beha io al, and biomedical sciences. Beha
Res Me hods. (2007) 39:175–91. doi: 10.3758/BF03193146
47. Pew Resea ch Cen e (2016). Resea ch in he c owdsou cing age: A case s udy.
A ailable a : h ps://www.pew esea ch.o g/in e ne /2016/07/11/ esea ch-in- he-
c owdsou cing-age-a-case-s udy/
48. Pew Resea ch Cen e (2023). Social media and news ac shee . A ailable a :
h ps://www.pew esea ch.o g/jou nalism/ ac -shee /social-media-and-news- ac -
shee /
49. Rosens ock IM. His o ical o igins o he heal h belie model. Heal h Educ
Monog . (1974) 2:328–35. doi: 10.1177/109019817400200403
50. S eche VJ, Rosens ock IM. The heal h belie model In: Camb idge Handbook
o Psychology, Heal h and Medicine. Camb idge: Camb idge Uni e si y P ess (1997).
117.
51. Johnson V, Bu e uss R, Kim J, O cu E, Ha sch R, Kendeou P. The ‘Fauci
e ec ’: educing COVID-19 misconcep ions and accine hesi ancy using an
au hen ic mul imodal in e en ion. Con emp Educ Psychol. (2022) 70:102084. doi:
10.1016/j.cedpsych.2022.102084
52. Gogol K, B unne M, Goe z T, Ma in R, Ugen S, Kelle U, e al. “My
ques ionnai e is oo long!” he assessmen s o mo i a ional-a ec i e cons uc s wi h
h ee-i em and single-i em measu es. Con emp Educ Psychol. (2014) 39:188–205.
doi: 10.1016/j.cedpsych.2014.04.002
53. Mu hén B, Mu hén L. Mplus In: Handbook o i em esponse heo y. ed. Wim J.
an de Linden Boca Ra on, FL: Chapman and Hall/CRC (2017). 507–18.
54. Wo ld Heal h O ganiza ion. Global COVID-19 accine s a egy in a changing wo ld:
June 2022 upda e. Wo ld Heal h O ganiza ion, Gene a, Swi ze land. (2022).
55. Nuwa da RF, Ramzan I, Weekes L, Kayse V. Vaccine hesi ancy: con empo a y
issues and his o ical backg ound. Vaccine. (2022) 10:1595. doi: 10.3390/
accines10101595
56. Wo ld Heal h O ganiza ion. Pandemic a igue– ein igo a ing he public o
p e en COVID-19: Policy amewo k o suppo ing pandemic p e en ion and
managemen . Gene a: Wo ld Heal h O ganiza ion (2020).
57. Du bach N. ‘They migh as well b and us’: wo king-class esis ance o
compulso y accina ion in Vic o ian England. Soc His Med. (2000) 13:45–63. doi:
10.1093/shm/13.1.45
21
Muis e al. 10.3389/ pubh.2024.1377973
F on ie s in Public Heal h 12 on ie sin.o g
58. Eisen E.X. (2021). The ma k o he beas . Geo gian B i ain’s an i-Vaxxe
mo emen . A ailable a : h ps://publicdomain e iew.o g/essay/ he-ma k-o - he-
beas -geo gian-b i ains-an i- axxe -mo emen
59. CDC (2021). His o ical accine sa e y conce ns. A ailable a : h ps://www.cdc.
go / accinesa e y/conce ns/conce ns-his o y.h ml
60. Kennedy EB, Daous JF, Vikse J, Nelson V. “Un il Iknow I ’s sa e o me”: he
ole o iming in COVID-19 accine decision-making and accine hesi ancy.
Vaccine. (2021) 9:1417. doi: 10.3390/ accines9121417
61. Gallup (2021). Mo e in US accina ed a e Del a su ge, FDA decision. A ailable
a : h ps://news.gallup.com/poll/355073/ accina ed-del a-su ge- da-decision.aspx
62. Di Leo I, Muis KR, Singh C, Psa adellis C. Cu iosi y. Con usion? F us a ion!
The ole and sequencing o emo ions du ing ma hema ics p oblem sol ing. Con emp
Educ Psychol. (2019) 58:121–37. doi: 10.1016/j.cedpsych.2019.03.001
63. da Cos a DiBona en u a M, Chapman GB. Mode a o s o he in en ion–
beha io ela ionship in in luenza accina ions: in en ion s abili y and un o eseen
ba ie s. Psychol Heal h. (2005) 20:761–74. doi: 10.1080/14768320500183368
22
F on ie s in Public Heal h 01 on ie sin.o g
Vaccine communica ion
s a egies among heal hca e
wo ke s as a e lec ion o he
Is aeli Minis y o Heal h’s
communica ion s a egies be o e
and a e he COVID-19 pandemic
RanaHijazi
1
*, Ana Gesse -Edelsbu g
1 and Gus a oS.Mesch
2
1 The Heal h and Risk Communica ion Lab, School o Public Heal h, Uni e si y o Hai a, Hai a, Is ael,
2 Depa men o Sociology, Uni e si y o Hai a, Hai a, Is ael
Backg ound: Heal hca e wo ke s play a cen al ole in communica ing
in o ma ion o he public ega ding accines. Mos o he li e a u e has ocused
on heal hca e wo ke s’ hesi ancy and doub s abou ge ing he lu accine
hemsel es. Howe e , ew s udies ha e deal wi h how hey pe cei e hei ole
in communica ing in o ma ion ega ding accines, especially ollowing he
COVID-19 pandemic.
Objec i es: (1) To iden i y he communica ion s a egies used by he Is aeli
Minis y o Heal h ega ding accines du ing epidemic c ises (be o e and a e
he COVID-19 pandemic); (2) To iden i y he communica ion s a egies used by
heal hca e wo ke s ega ding accines be o e and a e he COVID-19 pandemic.
Me hods: A quali a i e s udy based on in-dep h in e iews was conduc ed
among heal hca e wo ke s and used a semi-s uc u ed p o ocol as a esea ch
ool. A o al o 18 heal hca e wo ke s we e sampled using pu pose ul and
snowball sampling.
Resul s: Despi e heal hca e wo ke s’ pe cep ion ha he e has been a dec ease
in us in he Is aeli Minis y o Heal h among he public ollowing he COVID-19
ou b eak, hey s ill ely on he Is aeli Minis y o Heal h as hei p ima y sou ce o
in o ma ion and use he same communica ion s a egies (such as ea appeals
and co ec ing in o ma ion) as o he Is aeli Minis y o Heal h o communica e
wi h he public, heal hca e p o ide s, and o he ele an s akeholde s.
Conclusion: Heal hca e wo ke s ha e been shaped by he p o essional
socializa ion p ocesses wi hin he heal h sys em, leading o a p edominan
eliance on es ablished communica ion s a egies and in o ma ional channels.
This eliance unde sco es he impo ance o e ol ing hese me hods o be e
engage wi h he public. To add ess his, he e is a compelling need o inno a e
and adop new communica ion echniques ha emphasize e ec i e dialogue
and anspa en in e ac ions. By doing so, heal hca e p o essionals can ensu e
ha hei ou each is no only in o ma i e bu also esponsi e o he di e se
needs and p e e ences o he communi y.
KEYWORDS
accine hesi ancy, heal hca e wo ke s, COVID-19 pandemic, heal h communica ion
s a egies, quali a i e s udy, Is ael, pa en s, public us in he heal hca e sys em
OPEN ACCESS
EDITED BY
Ca los Albe o De Oli ei a Magalhães Júnio ,
S a e Uni e si y o Ma ingá, B azil
REVIEWED BY
Willian Melo,
S a e Uni e si y o Pa aná, B azil
Pie Luigi Sacco,
Uni e si y o S udies G. d'Annunzio Chie i and
Pesca a, I aly
*CORRESPONDENCE
Rana Hijazi
[email p o ec ed]
RECEIVED 27 Janua y 2024
ACCEPTED 07 May 2024
PUBLISHED 23 May 2024
CITATION
Hijazi R, Gesse -Edelsbu g A and
Mesch GS (2024) Vaccine communica ion
s a egies among heal hca e wo ke s as a
e lec ion o he Is aeli Minis y o Heal h’s
communica ion s a egies be o e and a e
he COVID-19 pandemic.
F on . Public Heal h 12:1377393.
doi: 10.3389/ pubh.2024.1377393
COPYRIGHT
© 2024 Hijazi, Gesse -Edelsbu g and Mesch.
This is an open-access a icle dis ibu ed
unde he e ms o he C ea i e Commons
A ibu ion License (CC BY). The use,
dis ibu ion o ep oduc ion in o he o ums is
pe mi ed, p o ided he o iginal au ho (s) and
he copy igh owne (s) a e c edi ed and ha
he o iginal publica ion in his jou nal is ci ed,
in acco dance wi h accep ed academic
p ac ice. No use, dis ibu ion o ep oduc ion
is pe mi ed which does no comply wi h
hese e ms.
TYPE O iginal Resea ch
PUBLISHED 23 May 2024
DOI 10.3389/ pubh.2024.1377393
23
Hijazi e al. 10.3389/ pubh.2024.1377393
F on ie s in Public Heal h 02 on ie sin.o g
In oduc ion
Heal h o ganiza ions du ing epidemics, and also when
communica ing in o ma ion abou child en’s ou ine accines, ha e
adop ed se e al communica ion s a egies o p omo e accina ion and
encou age he public o ge accina ed (1, 2). This s udy seeks o shed
ligh on some o he s a egies employed by heal hca e wo ke s be o e
and a e he COVID-19 c isis.
My h-bus ing – di e en ia ing be ween ac s and my hs – is
commonly used by heal h o ganiza ions. Acco ding o his app oach,
e e y piece o in o ma ion ha comes om o he sou ces besides he
heal h o ganiza ion i sel is labeled as a “my h,” while in o ma ion ha
o igina es om he heal h o ganiza ion i sel is labeled as “ ac ” (3).
Se e al s udies ha e no ed he p oblema ic use o his s a egy, which
was ound o esul in a back i e e ec (4–6); he public e used o accep
his in o ma ion unless i was suppo ed by scien i ic e idence (7–9). In
addi ion, epea ing he “my h” by he heal h o ganiza ions was ound o
make he in o ma ion mo e amilia and mo e likely o be ue (6).
Hence, s udies conduc ed du ing he COVID-19 ou b eak ound ha
heal h o ganiza ions con inue o use he same communica ion s a egies
o my h-bus ing and ea appeal s a egies (2, 10).
Heal h o ganiza ions also widely used he ea appeal s a egy
du ing p e ious disease ou b eaks. A ea appeal s a egy a emp s o
pe suade he public o adop a speci ic ac ion (such as accina ion o
compliance wi h ins uc ions) by a ousing ea . This s a egy is based
on emphasizing he po en ial dange and ha m ha migh esul i he
public does no adop he messages’ ecommenda ions (11). A
comp ehensi e me a-analysis o ea appeal li e a u e indica es ha
his s a egy is ine ec i e (12). Mo eo e , ea appeal has also been
associa ed wi h nega i e e ec s and esponses such as isk denial,
biased in o ma ion p ocessing, lowe le els o sel -e icacy, less
a en ion, and a highe le el o discom o a e being exposed o ea
appeal messages du ing a accine p omo ion campaign (13, 14).
P e ious s udies emphasized he appa en use o a ea appeal s a egy
by he Is aeli Minis y o Heal h du ing he COVID-19 accina ion
campaign (2). The use o his s a egy was cha ac e ized by he
language and one poli icians used o deli e in o ma ion in he media
(15, 16).
Heal h o ganiza ions ha e used hese communica ion s a egies
and eached he public h ough he media, especially h ough
channels such as social media in he las decade. Howe e , he p ima y
way o communica ing wi h he public is s ill h ough heal hca e
wo ke s, including nu ses and physicians. Heal hca e wo ke s a e
conside ed he ep esen a i es o heal h o ganiza ions and as such play
an essen ial ole in public accina ion (17). This ole includes
communica ing ecommenda ions, p o iding in o ma ion abou
accines, and accina ing he public (18). Physicians and o he
heal hca e p o ide s a e conside ed he mos eliable sou ce o
in o ma ion (19).
Pa en s pe cei e heal hca e wo ke s as a p ima y and us wo hy
sou ce o in o ma ion abou accina ion and accines (20) and play a
cen al ole in main aining public us in accina ion (21). Heal hca e
wo ke s’ ecommenda ions we e ound o bes ong d i e s o accine
accep ance among he public. The e o e, hey a e in a posi ion o
empowe pa en s o make an in o med decision abou accina ing
hei child en (19).
Due o he essen ial ole o heal hca e wo ke s in he accina ion
p ocess and as a us ed sou ce o in o ma ion o pa en s, as well as
in luencing he pa en s’ a i udes ega ding accina ion, he e is a need
o a be e unde s anding o how hey communica e accina ion
in o ma ion. This is u he suppo ed by he ac ha mos o he
s udies in he li e a u e on heal hca e wo ke s and accines ha e
ocused on accine hesi ancy, accine accep ance, and accina ion
in en ion among heal hca e wo ke s (22–24). Howe e , ew s udies
ha e deal wi h how heal hca e wo ke s pe cei e hei ole in
communica ing in o ma ion ega ding accines o he public,
especially ollowing he COVID-19 pandemic.
This s udy aims o (1) Iden i y he communica ion s a egies used
by he Is aeli Minis y o Heal h ega ding accines du ing epidemic
c ises (be o e and a e he COVID-19 pandemic); (2) Iden i y he
communica ion s a egies used by heal hca e wo ke s ega ding
accines be o e and a e he COVID-19 pandemic.
Me hods
Resea ch design and p ocedu e
This s udy is based on a quali a i e cons uc i is esea ch me hod
(25), which enables he esea che s o s udy he meaning o he
expe ience as i is pe cei ed by he esea ch subjec s. In his s udy,
heal hca e wo ke s hemsel es a e used as he ins umen o da a
collec ion o iden i y he communica ion s a egies employed by
heal hca e wo ke s and heal h o ganiza ions (26).
The s udy was app o ed by he Facul y o Social Wel a e and
Heal h Sciences E hics Commi ee o esea ch wi h human subjec s
a he Uni e si y o Hai a (app o al no. 421/17). The s udies we e
conduc ed in acco dance wi h he Is aeli Medical Resea ch In ol ing
Human Subjec s Law (1996) as he local legisla ion, and he
equi emen s and guidelines se by he Uni e si y o Hai a E hics
Commi ee. W i en in o med consen o pa icipa e in his s udy was
p o ided by he pa icipan s.
Sampling and da a collec ion
In he i s s age, he esea che s pe o med a pu pose ul c i e ion
sampling o heal hca e wo ke s such as amily physicians, pedia icians,
and nu ses who a e in ol ed in he accina ion p ocess wi h he public,
including gi ing accines and communica ing in o ma ion ega ding
accines o he public. In he second s age, he esea che s p oceeded
o pe o m snowball sampling. The s udy’s sample included 18
heal hca e wo ke s – 9 pedia icians, 1 physician, and 8 nu ses om
he Mo he and Child Heal h Clinics we e in e iewed (Table1). The
du a ion o each in e iew was app oxima ely hal an hou .
Resea ch ools
In-dep h in e iews we e conduc ed based on a semi-s uc u ed
p o ocol. In he i s pa , he ques ions e e ed o he pe iod
be o e he COVID-19 ou b eak in Is ael. The in e iewees we e
asked ques ions abou how hey communica e he issue o accines
o he pa en s, how he Is aeli Minis y o Heal h communica es he
issue o accines, how hey deal wi h unce ain y, and how hey
co ec misin o ma ion ega ding accines. In addi ion, he
24
Hijazi e al. 10.3389/ pubh.2024.1377393
F on ie s in Public Heal h 09 on ie sin.o g
I is impo an o no e, hough, ha hema ic sa u a ion was achie ed
wi hin he analysis. In addi ion, he sample consis ed o speci ic
ca ego ies o heal hca e wo ke s (pedia icians, a physician, and
nu ses), who p ima ily wo k a child heal h cen e s ha belong o he
Minis y o Heal h and heal h o ganiza ions. As such, i is possible ha
he a i udes and pe cep ions sha ed may no ully encompass he
di e si y o iews among Is ael’s b oade heal hca e communi y,
which includes a mo e ex ensi e a ay o p o essional oles and
specializa ions. The e o e, u u e s udies should include o he
heal hca e wo ke s besides he ones in he s udy sample. Fu he
s udies should also beconduc ed o e alua e he heal hca e wo ke s’
us in he heal h au ho i ies, due o a dea h o hese s udies in he
li e a u e. I is impo an o no e ha his s udy was pa ly conduc ed
be o e he COVID-19 ou b eak and esumed a e he COVID-19
accina ion campaign. The e o e, i aimed o add ess he change in
a i udes and pe cep ions among heal hca e wo ke s ega ding he
communica ion o he accine issue. Thus, ollow-up s udies on
heal hca e wo ke s’ communica ion s a egies should beconduc ed.
Conclusion
In summa y, he s udy’s indings indica e ha heal hca e
wo ke s ha e unde gone p o essional socializa ion by he heal h
sys em. Despi e heal hca e wo ke s’ pe cep ion ha he e has been
a dec ease in he public’s us in he Minis y o Heal h ollowing
he COVID-19 ou b eak, he wo ke s, hemsel es, con inue o
adop he same communica ion s a egies as he heal h au ho i ies.
The e o e, o inc ease he public’s us in bo h he heal hca e
sys em and in heal hca e wo ke s, mul i ace ed app oaches and
policies a e ecommended. Heal h o ganiza ions, au ho i ies, and
heal hca e wo ke s need o change hei communica ion s a egies
o egain public us . This includes anspa en ly p o iding
comple e in o ma ion, encou aging open dialogue o add ess
public conce ns and ea s, and empowe ing heal hca e wo ke s o
engage pa ien s h ough dedica ed discussion ime and
communica ion aining. Heal h au ho i ies and wo ke s should
also collabo a e on uni ied messaging campaigns o enhance
c edibili y, while ailo ing ou each e o s o acknowledge he
di e si y o public pe spec i es ac oss di e en demog aphic
g oups. I is impo an o no e ha while hese ecommenda ions
a e based on he indings om his s udy, he limi ed
gene alizabili y o he s udy should beconside ed.
Da a a ailabili y s a emen
The aw da a suppo ing he conclusions o his a icle will
bemade a ailable by he au ho s, wi hou undue ese a ion.
E hics s a emen
The s udies in ol ing humans we e app o ed by he Facul y o
Social Wel a e and Heal h Sciences E hics Commi ee o esea ch
wi h human subjec s a he Uni e si y o Hai a (app o al no. 421/17).
The s udies we e conduc ed in acco dance wi h he local legisla ion
and ins i u ional equi emen s. The pa icipan s p o ided hei w i en
in o med consen o pa icipa e in his s udy.
Au ho con ibu ions
RH: Concep ualiza ion, Da a cu a ion, Fo mal analysis,
In es iga ion, Valida ion, W i ing – o iginal d a , W i ing – e iew &
edi ing. AG-E: Concep ualiza ion, Fo mal analysis, Supe ision,
Valida ion, W i ing – o iginal d a , W i ing – e iew & edi ing. GM:
Supe ision, W i ing – e iew & edi ing.
Funding
The au ho (s) decla e ha no inancial suppo was ecei ed o
he esea ch, au ho ship, and/o publica ion o his a icle.
Acknowledgmen s
This s udy was pa o RH PhD disse a ion conduc ed a he
School o Public Heal h, Facul y o Social Wel a e and Heal h Sciences,
Uni e si y o Hai a, supe ised by AG-E and GM.
Con lic o in e es
The au ho s decla e ha he esea ch was conduc ed in he
absence o any comme cial o inancial ela ionships ha could
becons ued as a po en ial con lic o in e es .
The au ho (s) decla ed ha hey we e an edi o ial boa d membe
o F on ie s, a he ime o submission. This had no impac on he pee
e iew p ocess and he inal decision.
Publishe 's no e
All claims exp essed in his a icle a e solely hose o he au ho s
and do no necessa ily ep esen hose o hei a ilia ed o ganiza ions,
o hose o he publishe , he edi o s and he e iewe s. Any p oduc
ha may bee alua ed in his a icle, o claim ha may bemade by i s
manu ac u e , is no gua an eed o endo sed by he publishe .
Re e ences
1. Gesse -Edelsbu g A, Diaman A, Hijazi R, Mesch GS. Co ec ing misin o ma ion
by heal h o ganiza ions du ing measles ou b eaks: a con olled expe imen . PLoS One.
(2018) 13:e0209505. doi: 10.1371/jou nal.pone.0209505
2. Gesse -Edelsbu g A, Hijazi R, Cohen R. I akes wo o ango: how he
Co id-19 accina ion campaign in Is ael was amed by he heal h minis y s. he
ele ision news. F on Public Heal h. (2022) 10:887579. doi: 10.3389/ pubh.2022.887579
3. Cha on J, Gau ie A, Jes in C. In luence o in o ma ion sou ces on accine hesi ancy
and p ac ices. Med Mal In ec . (2020) 50:727–33. doi: 10.1016/j.medmal.2020.01.010
4. Manyibe EO. Top en cance my hs. J Appl Rehabil Couns. (2006) 37:36.
A ailable a : h ps://www.p oques .com/schola ly-jou nals/ op- en-cance -my hs/
doc iew/216484304/se-2
5. Mille K. Book e iew: Gi ls' iolence: my hs and eali ies. You h Violence Ju enile
Jus ice. (2007) 5:207–10. doi: 10.1177/1541204006296166
6. Signo ini A, Seg e AM, Polg een PM. The use o wi e o ack le els o disease
ac i i y and public conce n in he U.S. du ing he in luenza a H1n1 pandemic. PLoS
One. (2011) 6:e19467. doi: 10.1371/jou nal.pone.0019467
31
Hijazi e al. 10.3389/ pubh.2024.1377393
F on ie s in Public Heal h 10 on ie sin.o g
7. Baxendale S, O'Toole A. Epilepsy my hs: ali e and oaming in he 21s cen u y.
Epilepsy Beha . (2007) 11:192–6. doi: 10.1016/j.yebeh.2007.04.019
8. Challenge A, Sumne P, Bo L. Co id-19 my h-bus ing: an expe imen al s udy.
BMC Public Heal h. (2022) 22:131. doi: 10.1186/s12889-021-12464-3
9. Romo LK. “Abo e he in luence”: how college s uden s communica e abou he
heal hy de iance o alcohol abs inence. Heal h Commun. (2012) 27:672–81. doi:
10.1080/10410236.2011.629409
10. Gesse -Edelsbu g A. How o make heal h and isk communica ion on social media
mo e "social" du ing Co id-19. Risk Manag Heal hc Policy. (2021) 14:3523–40. doi:
10.2147/ mhp.S317517
11. Maddux JE, Roge s RW. P o ec ion mo i a ion and sel -e icacy: a e ised heo y
o ea appeals and a i ude change. J Exp Soc Psychol. (1983) 19:469–79. doi:
10.1016/0022-1031(83)90023-9
12. Tannenbaum MB, Heple J, Zimme man RS, Saul L, Jacobs S, Wilson K, e al.
Appealing o ea : a Me a-analysis o ea appeal e ec i eness and heo ies. Psychol Bull.
(2015) 141:1178–204. doi: 10.1037/a0039729
13. O A, Fah A. Using e icacy cues in pe suasi e heal h communica ion is mo e
e ec i e han employing h ea s – an expe imen al s udy o a accina ion in e en ion
agains Ebola. B J Heal h Psychol. (2018) 23:665–84. doi: 10.1111/bjhp.12310
14. Su Z, McDonnell D, Wen J, Cheshmehzangi A, Ahmad J, Goh E, e al. Young
Adul s' p e e ences o in luenza accina ion campaign messages: implica ions o
Co id-19 accine in e en ion design and de elopmen . B ain Beha Immun Heal h.
(2021) 14:100261. doi: 10.1016/j.bbih.2021.100261
15. Gesse -Edelsbu g A. Using na a i e e idence o con ey heal h in o ma ion on
social media: he case o Co id-19. J Med In e ne Res. (2021) 23:e24948. doi:
10.2196/24948
16. Gesse -Edelsbu g A, Hijazi R. When poli ics mee s pandemic: how p ime minis e
Ne anyahu and a small eam communica ed heal h and isk in o ma ion o he Is aeli
public du ing he ea ly s ages o Co id-19. Risk Manag Heal hc Policy. (2020)
13:2985–3002. doi: 10.2147/ mhp.S280952
17. ECD C. Communica ion on immunisa ion – Building us . S ockholm: Eu opean
Cen e o Disease P e en ion and Con ol (2012).
18. Boude F. Risk communica ion o accines: challenges in he pos - us en i onmen .
Cu D ug Sa . (2015) 10:9–15. doi: 10.2174/157488631001150407103916
19. Simone B, Ca illo-San is e e P, Lopalco PL. Heal hca e wo ke s’ ole in keeping
Mm accina ion up ake high in Eu ope: a e iew o e idence. Eu Secu . (2012)
17:20206. doi: 10.2807/ese.17.26.20206-en
20. Ve ge P, Dubé E. Res o ing con idence in accines in he Co id-19 e a. Expe Re
Vaccines. (2020) 19:991–3. doi: 10.1080/14760584.2020.1825945
21. Kempe A, Daley MF, McCauley MM, C ane LA, Suh CA, Kennedy AM, e al.
P e alence o pa en al conce ns abou childhood accines: he expe ience o p ima y
ca e physicians. Am J P e Med. (2011) 40:548–55. doi: 10.1016/j.amep e.2010.12.025
22. Pe e son CJ, Lee B, Nugen K. Co id-19 accina ion hesi ancy among heal hca e
wo ke s-a e iew. Vaccines (Basel). (2022) 10:948. doi: 10.3390/ accines10060948
23. Ve ge P, Bo elho-Ne e s E, Ga ison A, Gagnon D, Gagneu A, Gagneux-B unon
A, e al. Vaccine hesi ancy in heal h-ca e p o ide s in Wes e n coun ies: a na a i e
e iew. Expe Re Vaccines. (2022) 21:909–27. doi: 10.1080/14760584.2022.2056026
24. Willems LD, Dyzel V, S e kenbu g PS. Co id-19 accina ion in en ions amongs
heal hca e wo ke s: a scoping e iew. In J En i on Res Public Heal h. (2022) 19:10192.
doi: 10.3390/ije ph191610192
25. C eswell JW, Hanson WE, Cla k Plano VL, Mo ales A. Quali a i e esea ch
designs:selec ion and implemen a ion. Couns Psychol. (2007) 35:236–64. doi:
10.1177/0011000006287390
26. Lincoln YS, Guba EG. Na u alis ic inqui y. Newbu y Pa k, London, and New
Delhi: Sage (1985).
27. Lincoln YS, Guba EG, Pilo a JJ. Na u alis ic inqui y: Be e ly Hills, ca: sage
publica ions, 1985. In J In e cul Rela . (1985) 9:438–9. doi: 10.1016/0147-1767(85)90062-8
28. Lincoln YS. Eme ging c i e ia o quali y in quali a i e and in e p e i e esea ch.
Qual Inq. (1995) 1:275–89. doi: 10.1177/107780049500100301
29. B aun V, Cla ke V. Using hema ic analysis in psychology. Qual Res Psychol. (2006)
3:77–101. doi: 10.1191/1478088706qp063oa
30. Blai RA, Mo se BS, Tsai LL. Public heal h and public us : su ey e idence om
he Ebola i us disease epidemic in Libe ia. Soc Sci Med. (2017) 172:89–97. doi:
10.1016/j.socscimed.2016.11.016
31. OECD. Go e nmen a a glance 2013: P ocu emen da a. Oecd mee ing o leading
p ac i ione s on public p ocu emen . Pa is: O ganisa ion o Economic Co-ope a ion and
De elopmen . (2013).
32. Mu dan S, Ali N, Ashi u-O edope D. How o add ess accine hesi ancy. Pha m J.
(2021) 306:7949. A ailable a : h ps://pha maceu ical-jou nal.com/a icle/ld/how- o-
add ess- accine-hesi ancy
33. Fea he s one JD, Bell RA, Ruiz JB. Rela ionship o People's sou ces o heal h
in o ma ion and poli ical ideology wi h accep ance o conspi a o ial belie s abou
accines. Vaccine. (2019) 37:2993–7. doi: 10.1016/j. accine.2019.04.063
34. Fu LY, Zime GD, La kin CA, Joseph JG. Associa ions o us and heal hca e
p o ide ad ice wi h Hp accine accep ance among A ican Ame ican pa en s. Vaccine.
(2017) 35:802–7. doi: 10.1016/j. accine.2016.12.045
35. Ali-Saleh O, Bo d S, Basis F. Low esponse o he Co id-19 accine among he A ab
popula ion in Is ael: is i a cul u al backg ound, o a sys emic ailu e, o maybe bo h? J Racial
E hn Heal h Dispa i ies. (2023) 10:296–305. doi: 10.1007/s40615-021-01220-3
36. Bo d S, Scho A, Sa an C, Ali Saleh O, Inchi L, Halpe in D. Dis ancing adhe ence
and nega i e emo ions among he Is aeli elde ly popula ion du ing he Co id-19
pandemic. In J En i on Res Public Heal h. (2021) 18:8770. doi: 10.3390/ije ph18168770
37. Jennings W, S oke G, Bun ing H, Valga ðsson VO, Gaskell J, De ine D, e al. Lack
o us , conspi acy belie s, and social media use p edic Co id-19 accine hesi ancy.
Vaccines (Basel). (2021) 9:593. doi: 10.3390/ accines9060593
38. Sa an C, Ali-Saleh O, Mashiach-Eizenbe g M, Bo d S. S ess and pe cei ed
disc imina ion among he A ab popula ion in Is ael: he media ion ole o he pe cei ed
Co id-19 h ea and T us in he Heal hca e Sys em. E hn Heal h. (2022) 27:1377–94.
doi: 10.1080/13557858.2021.1899139
39. Sche nhamme E, Wei ze J, Laubichle MD, Bi mann BM, Be au M, Zenk L,
e al. Co ela es o Co id-19 accine hesi ancy in Aus ia: us and he go e nmen . J
Public Heal h (Ox ). (2022) 44:e106–16. doi: 10.1093/pubmed/ dab122
40. Shah abani S, Bo d S, Admi H, Halbe hal M. Physicians' compliance wi h
Co id-19 egula ions: he ole o emo ions and us . Heal hca e (Basel). (2022) 10:582.
doi: 10.3390/heal hca e10030582
41. Gesse -Edelsbu g A, Shi -Raz Y, Wal e N, Mo dini E, Dimi iou D, James JJ, e al.
The public sphe e in eme ging in ec ious disease communica ion: ecipien o ac i e and
ocal pa ne ? Disas e Med Public Heal h P ep. (2015) 9:447–58. doi: 10.1017/
dmp.2015.31
42. Gesse -Edelsbu g A, Abed Elhadi Shahba i N, Cohen R, Mi Hala i A, Hijazi R,
Paz-Yaakobo i ch G, e al. Di e ences in pe cep ions o heal h in o ma ion be ween he
public and heal h ca e p o essionals: nonp obabili y sampling ques ionnai e su ey. J
Med In e ne Res. (2019) 21:e14105. doi: 10.2196/14105
43. Ta u i S, Gallone MS, Cappelli MG, Ma inelli D, P a o R, Ge mina io C.
Add essing he an i- accina ion mo emen and he ole o Hcws. Vaccine. (2014)
32:4860–5. doi: 10.1016/j. accine.2013.11.006
44. Chang KC, S ong C, Pakpou AH, G i i hs MD, Lin CY. Fac o s ela ed o
p e en i e Co id-19 in ec ion beha io s among people wi h men al illness. J Fo mos
Med Assoc. (2020) 119:1772–80. doi: 10.1016/j.j ma.2020.07.032
45. Ha pe CA, Sa chell LP, Fido D, La zman RD. Func ional ea p edic s public
heal h compliance in he Co id-19 pandemic. In J Men Heal h Addic . (2021)
19:1875–88. doi: 10.1007/s11469-020-00281-5
46. S olow JA, Moses LM, Lede e AM, Ca e R. How ea appeal app oaches in
Co id-19 heal h communica ion may beha ming he global communi y. Heal h Educ
Beha . (2020) 47:531–5. doi: 10.1177/1090198120935073
47. Wi e K, Allen M. A Me a-analysis o ea appeals: implica ions o e ec i e public
heal h campaigns. Heal h Educ Beha . (2000) 27:591–615. doi: 10.1177/109019810002700506
48. Kiga ii a KK. E icacy o ea appeals on adop ion o Co id-19 p e en i e
measu es: a case o Boda Boda ide s in Nai obi Coun y, Kenya. In J Res G an haalayah.
(2020) 8:219–28. doi: 10.29121/g an haalayah. 8.i6.2020.533
49. Koois a EB, Reinde s Folme CP, Kuipe ME, Ol huis EH, B ownlee MA,
Fine A, e al. Mi iga ing Co id-19in a na ionally ep esen a i e UK sample:
Pe sonal abili ies and obliga ion o obey he law shape compliance wi h mi iga ion
measu es. A ailable a : h ps://pape s.ss n.com/sol3/pape s.c m?abs ac _
id=3598221 (Accessed May 11, 2020).
50. Mu phy K, Williamson H, Sa gean E, McCa hy M. Why people comply wi h
Co id-19 social dis ancing es ic ions: sel -in e es o du y? Aus N Z J C iminol. (2020)
53:477–96. doi: 10.1177/0004865820954484
51. Zoha T, Nege M, Si kin M, Le ine H. T us in Co id-19 policy among public
heal h p o essionals in Is ael du ing he i s wa e o he pandemic: a c oss-sec ional
s udy. Is J Heal h Policy Res. (2022) 11:20. doi: 10.1186/s13584-022-00529-6
52. Good ellow LM. P o essional socializa ion o s uden s en olled in an online doc o
o philosophy p og am in nu sing. J Nu s Educ. (2014) 53:595–9. doi: 10.3928/01484834-
20140922-06
53. Fes inge L. A heo y o cogni i e dissonance. S an o d, CA: S an o d Uni e si y
P ess (1962).
54. Shahba i NAE, Gesse -Edelsbu g A, Da ido i ch N, B ammli-G eenbe g S, G i a
R, Mesch GS. Fac o s associa ed wi h seasonal in luenza and Hp accina ion up ake
among di e en e hnic g oups in A ab and Jewish Socie y in Is ael. In J Equi y Heal h.
(2021) 20:201. doi: 10.1186/s12939-021-01523-1
55. Pea ce L, Coope J. Fos e ing Co id-19 sa e beha io s using cogni i e dissonance.
Basic Appl Soc Psychol. (2021) 43:267–82. doi: 10.1080/01973533.2021.1953497
56. Ha mon-Jones E, Ha mon-Jones C. Cogni i e dissonance heo y a e 50 yea s o
de elopmen . Z Sozialpsychol. (2007) 38:7–16. doi: 10.1024/0044-3514.38.1.7
57. Ha mon-Jones E, Mills J. An in oduc ion o cogni i e dissonance heo y and an
o e iew o cu en pe spec i es on he heo y. Cogni i e dissonance: Reexamining a pi o al
heo y in psychology, 2nd Ed. Washing on, DC, US: Ame ican Psychological Associa ion
(2019). p. 3–24.
32
Hijazi e al. 10.3389/ pubh.2024.1377393
F on ie s in Public Heal h 11 on ie sin.o g
58. MacDonald NE, Comeau J, Dubé È, G aham J, G eenwood M, Ha mon S, e al.
Royal Socie y o Canada Co id-19 epo : enhancing Co id-19 accine accep ance in
Canada. Face s. (2021) 6:1184–246. doi: 10.1139/ ace s-2021-0037
59. Me in I, Camgoz SM. The ad ances in he his o y o cogni i e dissonance heo y.
In J Humani Soc Sci. (2011) 1:131–6. A ailable a : h ps://www.ijhssne .com/ iew.
php?u=h p://www.ijhssne .com/jou nals/Vol._1_No._6;_June_2011/14.pd
60. Bem DJ. Sel -pe cep ion: an al e na i e in e p e a ion o cogni i e dissonance
phenomena. Psychol Re . (1967) 74:183–200. doi: 10.1037/h0024835
61. Bem DJ. Sel -pe cep ion heo y In: L Be kowi z, edi o . Ad ances in expe imen al
social psychology, ol. 6. New Yo k and London: Academic P ess (1972). 1–62.
62. Tedeschi JT, Schlenke BR, Bonoma TV. Cogni i e dissonance:
p i a e a iocina ion o public spec acle? Am Psychol. (1971) 26:685–95. doi: 10.1037/h0032110
63. Fes inge L, Ca lsmi h JM. Cogni i e consequences o o ced compliance. J
Abno m Soc Psychol. (1959) 58:203–10. doi: 10.1037/h0041593
64. Heine S. J., and Lehman D. R. Cul u e, dissonance, and sel -a i ma ion. Pe s. Soc.
Psychol. Bull. (1997) 23:389–400. doi: 10.1177/0146167297234005
65. A onson E. The e u n o he ep essed: dissonance heo y makes a comeback.
Psychol Inq. (1992) 3:303–11. doi: 10.1207/s15327965pli0304_1
66. A onson E. The heo y o cogni i e dissonance: he e olu ion and icissi udes o an
idea. The message o social psychology: pe spec i es on mind in socie y. Malden: Blackwell
Publishing (1997). p. 20–35.
67. Coope J, Fazio RH. A new look a dissonance heo y In: L Be kowi z, edi o .
Ad ances in expe imen al social psychology, ol. 17. New Yo k and London: Academic
P ess (1984). 229–66.
68. Ha mon-Jones E. Towa d an unde s anding o he mo i a ion unde lying
dissonance e ec s: is he p oduc ion o a e si e consequences necessa y? Cogni i e
dissonance: P og ess on a pi o al heo y in social psychology. Science Con e ence
Se ies. Washing on, DC, US: Ame ican Psychological Associa ion (1999). p. 71–99.
69. Heide F. A i udes and cogni i e o ganiza ion. J Psychol. (1946) 21:107–12. doi:
10.1080/00223980.1946.9917275
70. Lan J, Huo Y, Cai Z, Wong CS, Chen Z, Lam W. Unco e ing he impac o iadic
ela ionships wi hin a eam on job pe o mance: an applica ion o balance heo y in
p edic ing eedback-seeking beha iou . J Occup O gan Psychol. (2020) 93:654–86. doi:
10.1111/joop.12310
33
F on ie s in Public Heal h 01 on ie sin.o g
De e minan s o in luenza
non- accina ion among
Canadian child en: insigh s om
a na ionwide su ey
AbdallahAlami
1
*, SaillyDa e
1, Ca enUhlik
1, Ma waEb ahim
1,
DanielK ewski
2 and JulieLa oche
1
1 Vaccine Co e age and E ec i eness Su eillance Di ision, In ec ious Diseases and Vaccina ion
P og ams B anch, Public Heal h Agency o Canada, O awa, ON, Canada, 2 School o Epidemiology
and Public Heal h, Facul y o Medicine, Uni e si y o O awa, O awa, ON, Canada
Backg ound: To iden i y de e minan s in luencing Canadian pa en s’ decision
no o accina e hei child en aged 6 mon hs o 17 yea s agains seasonal
in luenza.
Me hods: Da a om he 2022 Childhood COVID-19 Immuniza ion Co e age
Su ey, a na ional su ey o app oxima ely 10,500 Canadian pa en s/gua dians and
hei child en, was analyzed. The su ey examined in luenza accine co e age,
pa en al pe spec i es on accines, easons o hesi ancy, and ac o s in luencing
immuniza ion. Socio-demog aphic cha ac e is ics, including e hnici y,
household income, wo king sec o , educa ional a ainmen , and p e alence o
ch onic medical condi ions among child en we e conside ed. His o ical accine
up ake and he impac o he COVID-19 pandemic on immuniza ion decisions
we e also e iewed. Key de e minan s o non- accina ion in he 2021–2022
in luenza season we e analyzed using mul i a iable logis ic eg ession, wi h a
s a is ical signi icance le el se a p- alue <0·05.
Resul s: 70% o child en aged 6 mon hs o 17 yea s did no ecei e he seasonal
in luenza accine. Key p edic o s o non- accina ion included: esiding in u al
se ings (aOR 1·35, 95% CI 1·13–1·60), pa en al educa ion a ainmen o less han
high school (aOR 2·48, 95% CI 1·24–4·97), and he absence o ch onic medical
condi ions in child en (aOR 1.60, 95% CI 1.34-1.91)· O he s ong p edic o s
included lowe household income; de e ence due o he COVID-19 pandemic;
and pa en al hesi ancy s emming om conce ns abou he accine’s sa e y,
e ec i eness, and by belie s ha hei child was no a isk o con ac ing he
in luenza o se e e consequences om he in ec ion.
Conclusion: This esea ch unde sco es pi o al de e minan s o pa en al
decisions no o accina e hei child en agains seasonal in luenza and sheds
ligh on he impac o he COVID-19 pandemic. The esul s highligh he
impo ance o add essing sa e y conce ns and p o iding clea in o ma ion o
alle ia e hesi ancy.
KEYWORDS
in luenza, su ey, accine hesi ancy, public heal h, immuniza ion, COVID-19, Canada
OPEN ACCESS
EDITED BY
Ca los Albe o De Oli ei a Magalhães Júnio ,
S a e Uni e si y o Ma ingá, B azil
REVIEWED BY
Nu ia To ne ,
Uni e si y o Ba celona, Spain
Fo ino Soló zano-San os,
Fede ico Gómez Child en's Hospi al, Mexico
*CORRESPONDENCE
Abdallah Alami
[email protected]
RECEIVED 14 Ma ch 2024
ACCEPTED 16 May 2024
PUBLISHED 05 June 2024
CITATION
Alami A, Da e S, Uhlik C, Eb ahim M,
K ewski D and La oche J (2024) De e minan s
o in luenza non- accina ion among
Canadian child en: insigh s om a na ionwide
su ey.
F on . Public Heal h 12:1400782.
doi: 10.3389/ pubh.2024.1400782
COPYRIGHT
© 2024 Alami, Da e, Uhlik, Eb ahim, K ewski
and La oche. This is an open-access a icle
dis ibu ed unde he e ms o he C ea i e
Commons A ibu ion License (CC BY). The
use, dis ibu ion o ep oduc ion in o he
o ums is pe mi ed, p o ided he o iginal
au ho (s) and he copy igh owne (s) a e
c edi ed and ha he o iginal publica ion in
his jou nal is ci ed, in acco dance wi h
accep ed academic p ac ice. No use,
dis ibu ion o ep oduc ion is pe mi ed
which does no comply wi h hese e ms.
TYPE O iginal Resea ch
PUBLISHED 05 June 2024
DOI 10.3389/ pubh.2024.1400782
34
Alami e al. 10.3389/ pubh.2024.1400782
F on ie s in Public Heal h 02 on ie sin.o g
In oduc ion
Childhood accina ion is undamen al in main aining he heal h
o bo h indi iduals and he b oade communi y, especially when i
comes o he seasonal in luenza. This espi a o y illness, hough
common, can lead o se e e heal h complica ions, especially in young
child en and people o e 65 yea s o age, as well as in hose wi h
unde lying ch onic heal h condi ions (1, 2).
Child en a e pa icula ly ulne able o he seasonal in luenza,
wi h da a om Canada showing hey a e disp opo iona ely a ec ed
(3). Complica ions om in luenza in child en can include pneumonia,
dehyd a ion, and wo sening o long- e m medical p oblems such as
hea disease o as hma, sinus p oblems, and ea in ec ions (4). In a e
cases, in luenza complica ions can lead o dea h (4). Acco ding o he
Canadian Immuniza ion Moni o ing P og am Ac i e (IMPACT)
su eillance ne wo k, be ween 2004 and 2005 and 2012–2013
(excluding he 2009–2010 pandemic season) pedia ic seasonal
in luenza was con i med in 15·5% o 58·3% o hospi al admissions in
child en 16 yea s o age and younge (5, 6). In he wake o he
COVID-19 pandemic, he 2022–2023 seasonal in luenza season in
Canada ma ked a signi ican shi , esembling p e-pandemic seasonal
in luenza ac i i y bu wi h no able impac on pedia ic popula ion (7).
Acco ding o he Na ional In luenza Annual Repo , Canada, 2022–
2023, which d aws on FluWa ch da a (a long-s anding na ional
su eillance sys em moni o ing he sp ead o in luenza and in luenza-
like illness in Canada), nea ly hal (45%; n = 6,194/13,729) o he
epo ed in luenza A de ec ions occu ed in he pedia ic popula ion
(younge han 19 yea s) (7). Fu he mo e, when hospi aliza ions a e
b oken down by ype, he pedia ic popula ion accoun ed o 49% o
hospi aliza ions associa ed wi h in luenza B, compa ed o 22% o
in luenza A (7). Addi ionally, du ing his pe iod, weekly pedia ic
in luenza-associa ed hospi al admissions pe sis en ly exceeded
his o ical peak le els, wi h child en aged 0–4 yea s being he mos
a ec ed g oup, expe iencing he highes cumula i e hospi aliza ion
a e a 131 pe 100,000 popula ion (7).
Gi en hese indings, and o mi iga e he po en ial complica ions
o seasonal in luenza in ec ion in child en, he Na ional Ad iso y
Commi ee on Immuniza ion (NACI) con inues o ecommend ha
he seasonal in luenza accine should beo e ed annually o anyone
6 mon hs o age and olde who does no ha e a con aindica ion o he
accine (5). Despi e he a ailabili y o an e ec i e accine, many
pa en s a e choosing no o accina e hei child en agains he
in luenza (8). Gaining insigh s in o he easons behind hese decisions
is c i ical no only o boos accina ion a es, bu also o ensu e he
b oade communi y emains p o ec ed. Wi h accine hesi ancy
equen ly exp essed du ing he ecen COVID-19 pandemic,
moni o ing and unde s anding pa en al a i udes owa d accina ion
is c i ical o inc easing seasonal in luenza accina ion up ake. Pa en al
pe cep ions can p o ide insigh in o expec ed accine up ake and can
help shape public educa ional and awa eness campaigns. This is
pa icula ly impo an gi en he high deg ee o unce ain y in
es ima es o seasonal in luenza accine co e age in child en. This
s udy aims o explo e ac o s associa ed wi h non- accina ion agains
he seasonal in luenza in Canadian pa en s o child en aged 6 mon hs
o 17 yea s old. The esul s o his s udy can p o ide aluable insigh s
in o pa en al a i udes and belie s abou in luenza accina ion and
in o m he de elopmen o a ge ed in e en ions aimed a inc easing
seasonal in luenza accina ion a es and p o ec ing public heal h.
Me hods
Da a sou ce
This s udy u ilizes da a om he 2022 Childhood COVID-19
Immuniza ion Co e age Su ey (CCICS) (9), an annual su ey i s
implemen ed by he Public Heal h Agency o Canada in 2022. Da a
collec ion o his su ey was conduc ed o e a pe iod ex ending om
Ap il 20 o July 21, 2022. The su ey cons i u es a na ionally ep esen a i e
da ase o Canadian pa en s o gua dians wi h child en in speci ic age
g oups (0–4, 5–11, and 12–17 yea s). CCICS encompasses all Canadian
p o inces and e i o ies and ensu es a balanced ep esen a ion o males
and emales. As a su eillance ool, CCICS p o ides bo h na ional and
p o incial/ e i o ial-le el es ima es o se e al key ac o s, including
seasonal in luenza accine co e age among eligible child en; knowledge,
a i udes, and belie s (KAB) o esponden s owa d accina ions; and
ba ie s and acili a o s o immuniza ion. The su ey also p o ides
in o ma ion abou he impac o he COVID-19 pandemic on accina ion
decisions, as well as accina ion his o y and up ake among child en and
hei pa en s o gua dians. Socio-demog aphic da a including household
income, wo king sec o , educa ion, and ci izenship s a us in Canada a e
also collec ed in he su ey.
S udy design
This c oss-sec ional s udy employed a p obabili y-based sampling
s a egy, whe e he CCICS aimed o a sample size o 10,500 Canadian
pa en s o gua dians 18 yea s o age o olde . To achie e a na ionally
ep esen a i e sample, esponden s we e ec ui ed om a gene al
popula ion sample by andom digi dialing (RDD) (10), ac oss all
p o inces and e i o ies. The sampling amewo k allows o
ex apola ion o he b oade Canadian popula ion. To s eng hen
s a is ical powe and ensu e na ional ep esen a i eness, quo as we e
se o key sub-popula ions.1 Su ey sampling weigh s we e applied o
mi o he demog aphic composi ion o he Canadian popula ion o
child en, based on child’s sex, child’s age g oup and p o ince o
e i o y o esidence (based on he mos ecen da a om he 2021
S a is ics Canada census). Boo s aps we e gene a ed and applied o
es ima e a iance. O e all, 100·3% o he a ge sample size was
success ully achie ed, ensu ing ha he s udy had adequa e powe .
Da a collec ion
Da a was cap u ed using a mul imodal app oach, adminis e ed
ei he online o h ough compu e assis ed elephone in e iewing
(CATI). CATI was speci ically done in ha d- o- each popula ions o
inc ease esponse a es ( a ge ing pa en s in A lan ic and No he n
p o inces/ e i o ies who a e o en mo e di icul o each online).
This lexible app oach acili a ed comp ehensi e da a collec ion ac oss
di e se demog aphic g oups.
1 Key sub-popula ions o quo as included: pa en s wi h child en aged 0–4,
5–11, and 12–17 yea s; pa en s om all p o inces and e i o ies; and a gende
balance among child en (50% males, 50% emales).
35
Alami e al. 10.3389/ pubh.2024.1400782
F on ie s in Public Heal h 03 on ie sin.o g
Inclusion and exclusion c i e ia
In alignmen wi h Heal h Canada’s seasonal in luenza accina ion
au ho iza ion s a ing a 6 mon hs o age, his analysis pu posely excludes
da a on child en younge han 6 mon hs. Resul s a e he e o e based on
su ey esponses om pa en s o gua dians o child en aged 6 mon hs o
17 yea s ac oss all Canadian p o inces and e i o ies. Missing da a we e
no expec ed o pose a signi ican issue. A h eshold o da a emo al was
es ablished: any a iable exhibi ing mo e han 20% missing da a was
excluded om he eg ession analysis. To assess he andomness o
missing alues in he da ase , we gene a ed g aphical summa ies
isualizing he pa e ns o missingness ac oss a iables: his isualiza ion
was pe o med o a iables wi h mo e han 5% o missing da a, allowing
o an e alua ion o whe he he missing alues demons a ed
any disce nable ends o pa e ns (Supplemen a y ma e ial,
Supplemen a y Figu e S1).
S a is ical and da a analysis
R S a is ical So wa e ( e sion 4·1·3; R Founda ion o S a is ical
Compu ing, Vienna, Aus ia) was used o da a analysis, including
da a il e ing, analysis and w angling, and bo h desc ip i e and
in e en ial s a is ical analyses (11). Ini ial da a explo a ion in ol ed
summa izing ca ego ical dependen and independen a iables using
desc ip i e s a is ics. Unweigh ed and weigh ed equencies and
p opo ions we e calcula ed, s a i ied by seasonal in luenza
accina ion s a us. Like plo s we e used o summa ize pa en al
opinions on key KAB ques ions abou accines: his g aphical
ep esen a ion displayed he ange o pa en al esponses, om
‘S ongly Ag ee’ o ‘S ongly Disag ee,’ o a ious belie s a emen s
abou accine sa e y and e ec i eness.
In line wi h ou esea ch objec i es, weanalyzed and inco po a ed
pa en al hesi ancy, along wi h i s unde lying easons, o be e
unde s and de e minan s o child en’s non- accina ion agains seasonal
in luenza. In he su ey, pa en s we e asked abou hei hesi ancy o
accina e hei child agains he in luenza du ing he 2021–2022 season.
Those who indica ed hesi ancy we e p omp ed o selec hei speci ic
eason(s). Gi en ha esponden s could choose mul iple easons,
weca ego ized hese in o h ee b oad ca ego ies o analy ical pu poses:
1. conce ns abou accine e ec i eness, sa e y, and pe cei ed isk
which encompassed doub s abou he in luenza accine’s
e icacy, child en’s suscep ibili y o lu, po en ial accine side
e ec s, conce ns ega ding combined in luenza and COVID
accina ions, and pas ad e se accine e en s;
2. ba ie s ela ed o access and in o ma ion a ailabili y, including
hesi ancy due o challenges in discussing he in luenza accine
wi h heal hca e expe s, sou cing us wo hy in o ma ion, and
un a o able encoun e s wi h medical p ac i ione s; and
3. pe sonal belie s and o he in luences, such as eligious o
philosophical s ances and ea s o acism o disc imina ion.
F om hese ca ego ies, wede eloped a i e-le el classi ica ion
sys em o analysis:
• “No Hesi an ,”
• “Hesi an : E ec i eness/Sa e y/Pe cei ed Risk” (de i ed om he
i s ca ego y),
• “Hesi an : Access/In o ma ion” ( om he second ca ego y),
• “Hesi an : Pe sonal/O he In luences” ( e lec ing he hi d
ca ego y),
• “Hesi an : Mul iple Reasons” ( o hose indica ing easons ac oss
mul iple ca ego ies).
This s uc u ed app oach no only en iched ou unde s anding o
he mul i ace ed in luences on accina ion hesi ancy, bu also was
ins umen al o ou eg ession models. The i e-le el classi ica ion
sys em acili a ed a comp ehensi e explo a ion o he ela ionship
be ween in luenza accine hesi ancy, accine up ake, and he speci ic
pa en al easons behind hesi ancy.
A mul i a iable logis ic eg ession model was employed o explo e
ac o s associa ed wi h non- accina ion o child en aged 6 mon hs o
17 yea s agains he seasonal in luenza. To accoun o he complexi ies o
ou su ey design, wees ima ed s anda d e o s, coe icien s o a ia ion,
and con idence in e als using he boo s ap echnique (12). As a s a ing
poin , uni a ia e logis ic eg ession analyses we e i o he su ey da a o
each p edic o o de i e unadjus ed odds a ios (ORs), wi h con idence
in e al (CI) se a 95%. Va iables no achie ing s a is ical signi icance a
his s age we e no immedia ely excluded; a he , as hei e ec could
become appa en in a mul i a iable con ex a e con olling o o he
a iables, hey we e ea ma ked o po en ial emo al in la e s ages.
To add ess mul icollinea i y among ca ego ical p edic o s,
weemployed C ame ’s V, guided by h esholds es ablished by Lee e al.
(13). P edic o s exceeding a C ame ’s V alue o 0·4 we e lagged o
emo al o mi iga e he e ec s o a possible mul icollinea i y. Weadop ed
a ‘bes i ’ s a egy o cons uc ion mul i a iable models. This en ailed
ini ially inco po a ing all ele an p edic o s, including hose ha
showed s a is ically insigni ican e ec s in he uni a ia e analysis bu
we e deemed p ac ically signi ican . A s epwise backwa d elimina ion
p ocess was hen conduc ed, guided by he Akaike In o ma ion C i e ion
(AIC), p- alues, and adjus men s o mul iple compa isons. The inal
model was selec ed based on a combina ion o s a is ical signi icance,
minimized AIC alues and domain expe ise. Adjus ed odds a ios
(aOR) we e used o e alua e ela ionships be ween p edic o s and he
ou come o non- accina ion among child en. A likelihood a io es was
used o alida e he goodness o i o he inal model (14).
An odds a io plo was gene a ed using ggplo 2 and Final i
packages in R (15) o isualize p edic o s and hei espec i e aORs in
he inal model: his plo included 95% CI on he aORs o gage he
impac o each a iable on he likelihood o non- accina ion in child en.
Resul s
Sociodemog aphic cha ac e is ics o he
su ey popula ion
A o al o 10,536 indi iduals pa icipa ed in he su ey, achie ing
an o e all esponse a e o 26·1%.
O hese, 10,236 esponden s we e included in he analysis, as
esponses om pa en s o gua dians o child en unde 6 mon hs o
age we e no included. Table 1 p esen s he sociodemog aphic
cha ac e is ics o he su ey popula ion, s a i ied by accina ion
s a us. This able p o ides a comp ehensi e o e iew o he sample
popula ion ac oss di e en a iables, including p o ince/ e i o y, age
o child and esponding pa en , sex, u ban/ u al se ing, e hnici y, and
household income.
36
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F on ie s in Public Heal h 04 on ie sin.o g
TABLE1 Sociodemog aphic cha ac e is ics o su ey esponden s, s a i ied by child seasonal in luenza accina ion s a us.
O e all Vaccina ed child en Un accina ed child en
Cha ac e is ic N (%)1N (%)1N (%)1
Sample size 10,236 (100·0) 3,230 (30·0) 7,006 (70·0)
P o ince/Te i o y
Albe a (AB) 1,240 (13·5) 463 (17·3) 777 (11·8)
B i ish Columbia (BC) 1,342 (12·1) 444 (13·6) 898 (11·5)
Mani oba (MB) 399 (4·3) 180 (6·6) 219 (3·3)
New B unswick (NB) 382 (1·9) 139 (2·2) 243 (1·7)
New oundland and Lab ado (NL) 389 (1·2) 168 (1·7) 221 (0·9)
No a Sco ia (NS) 408 (2·3) 159 (3·0) 249 (2·0)
On a io (ON) 3,019 (37·9) 932 (39·3) 2,087 (37·4)
P ince Edwa d Island (PE) 386 (0·4) 165 (0·6) 221 (0·3)
Quebec (QC) 1,945 (22·2) 251 (9·5) 1,694 (27·6)
Saska chewan (SK) 404 (3·8) 175 (5·5) 229 (3·1)
Te i o ies 322 (0·4) 154 (0·7) 168 (0·3)
Child age
6 mon hs – 4 yea s 2,551 (25·1) 1,047 (33·4) 1,504 (21·5)
5–11 yea s 3,724 (40·4) 1,166 (39·1) 2,558 (40·9)
12–17 yea s 3,961 (34·6) 1,017 (27·6) 2,944 (37·6)
Age o esponding pa en
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 a bi h
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 o esponding pa en
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)
U ban/ u al se ing
U ban 8,415 (86·1) 2,743 (89·7) 5,672 (84·5)
Ru al 1,737 (13·9) 475 (10·3) 1,262 (15·5)
E hnici y o esponding pa en
Black 267 (2·9) 38 (1·3) 229 (3·6)
Eas /Sou heas Asian 457 (4·4) 176 (5·5) 281 (3·9)
Sou h Asian descen 304 (3·5) 94 (3·4) 210 (3·5)
La in Ame ican 153 (1·7) 44 (1·4) 109 (1·8)
Middle Eas e n and No h A ican 222 (2·5) 54 (1·9) 168 (2·7)
Indigenous 158 (0·9) 52 (0·9) 106 (0·9)
Whi e Eu opean descen 7,825 (79·1) 2,572 (80·8) 5,253 (78·3)
O he /Mixed pa en e hnici y 476 (5·1) 138 (4·8) 338 (5·3)
Educa ion o esponding pa en
Less han high school 134 (1·1) 25 (0·4) 109 (1·4)
High school o equi alen 808 (7·3) 212 (6·1) 596 (7·9)
Pos seconda y below Bachelo ’s 3,247 (31·5) 766 (22·1) 2,481 (35·6)
Bachelo ’s o abo e 5,926 (60·0) 2,209 (71·3) 3,717 (55·1)
(Con inued)
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F on ie s in Public Heal h 05 on ie sin.o g
Thi y pe cen (30·0%, N = 3,230) o child en younge han
18 yea s we e accina ed agains seasonal in luenza. A majo i y o he
esponding pa en s/gua dians we e emale (60·8%) and o Whi e
Eu opean descen (79·1%). Nea ly wo hi ds o he pa en s (60·0%)
had a bachelo ’s deg ee o highe , wi h 39·4% epo ing being
employed in high- isk sec o s (including heal h ca e o labo a o y
wo ke s, hose wo king in child ca e o schools, hose exposed o
animals o hei ma e ials, and eme gency se ices wo ke s). Child en
anged in age om 6 mon hs o 4 yea s (25·1%), 5 o 11 yea s (40·4%),
and 12 and 17 yea s (34·6%). A small mino i y o child en had ch onic
medical condi ions (12·4%) and disabili ies (6·5%).
P e-Pandemic and cu en seasonal
in luenza accina ion pa e ns among
pa en s and child en
P io o he COVID-19 pandemic, 42·7% o pa en s indica ed
ha hey ypically ecei ed an seasonal in luenza accine ei he e e y
in luenza season o mos seasons. Howe e , o he 2021–2022
in luenza season, wo- hi ds (66·9%) o pa en s op ed ou o ecei ing
he accine, while only one- hi d (33·1%) epo ed ge ing accina ed
(Table 2). When asked abou hei child’s seasonal in luenza
accina ion s a us p io o he COVID-19 pandemic, 38·4% o
pa en s indica ed accina ing hei child e e y o mos in luenza
seasons, 18·5% epo ed ha ing hei child en accina ed some imes,
and 43·1% epo ed ne e accina ing hei child agains he lu. A
g ea majo i y o pa en s (93·3%) epo ed ha hei child had
ecei ed all ecommended ou ine accina ions, wi h a u he 4·2%
ecei ing pa ial accina ions, and 2·4% emaining un accina ed.
Conce ning he likelihood o ha ing hei child accina ed
agains seasonal in luenza in he upcoming season, app oxima ely
hal (50·3%) o pa en s signaled s ong in en (ei he ‘de ini ely will’
o ‘p obably will’) o ha e hei child en accina ed; 22·9% o pa en s
exp essed a mode a e likelihood o a oiding accina ion, saying hey
‘p obably will no ’, while 18·9% exp essed s ong iews agains
accina ion, esponding wi h ‘de ini ely will no ’.
The mos common mo i a ion o pa en s accina ing hei child
was sel and household p o ec ion om seasonal in luenza (85·0%),
ollowed by desi e o p e en he sp ead o seasonal in luenza in he
TABLE1 (Con inued)
O e all Vaccina ed child en Un accina ed child en
S a us o esidency in Canada
Canadian by bi h 8,111 (78·5) 2,684 (82·1) 5,427 (76·9)
Canadian by na u aliza ion 1,578 (17·0) 405 (14·1) 1,173 (18·3)
Pe manen esiden /landed
immig an
447 (4·1) 122 (3·5) 325 (4·4)
Re ugee claiman /Asylum seeke s 9 (0·1) 4 (0·1) 5 (0·1)
Tempo a y esiden 36 (0·2) 9 (0·2) 27 (0·3)
Wo king sec o o esponding pa en
High- isk sec o 23,970 (39·4) 1,326 (40·4) 2,644 (38·9)
No high- isk sec o 5,969 (60·6) 1,859 (59·6) 4,110 (61·1)
To al household income ($)
Unde 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 abo e 3,522 (38·2) 1,414 (48·8) 2,108 (33·5)
P e alence o ch onic condi ions among child en
Wi h ch onic condi ion31,285 (12·4) 473 (14·7) 812 (11·4)
Wi hou ch onic condi ion 8,835 (87·6) 2,729 (85·3) 6,106 (88·6)
P e alence o disabili ies among child en
Wi h disabili y4675 (6·5) 197 (6·0) 478 (6·7)
Wi hou disabili y 9,477 (93·5) 3,011 (94·0) 6,466 (93·3)
1Pe cen weigh ed by: egion, child’s age g oup, and child’s sex a bi h.
2High-Risk Wo king Sec o : This ca ego y includes indi iduals cu en ly employed o olun ee ing in sec o s wi h ele a ed exposu e isks. These sec o s encompass heal hca e, labo a o y
se ices, childca e, educa ional ins i u ions, occupa ions wi h animal exposu e, eme gency se ices, and o he c i ical oles such as s a in co ec ional acili ies, c ew on ships o ai c a ,
mili a y pe sonnel, humani a ian elie wo ke s, and p o ide s o essen ial communi y se ices.
3Ch onic Medical Condi ion: This e e s o heal h condi ions as ou lined in he Canadian Immuniza ion Guide and include sickle cell anemia o halassemia majo , neu ological o
neu ode elopmen al diso de s, as hma and o he ch onic espi a o y diseases, ch onic condi ions a ec ing he li e , hea , o kidneys, diabe es, obesi y, Down Synd ome, immune supp ession
(due o chemo he apy, adio he apy, s e oid use, HIV, o gan ansplan s), cance , and o he signi ican medical condi ions.
4Disabili y: This is de ined as a pe son who has a long- e m o ecu ing impai men (such as ision, hea ing, mobili y, lexibili y, dex e i y, pain, lea ning, de elopmen al, memo y o men al
heal h- ela ed) which limi s hei daily ac i i ies inside o ou side he home (such as a school, wo k, o in he communi y in gene al).
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F on ie s in Public Heal h 06 on ie sin.o g
communi y (49·0%), and he ac ha he child ecei es he accine
annually (48·0%).2
Pa en al a i udes, in luences, and ba ie s
o seasonal in luenza accina ion
A subs an ial majo i y o pa en s exp essed a o able opinions
ega ding gene al accine sa e y and e ec i eness. Speci ically, 91·4%
2 As pa icipan s could selec mul iple op ions, pe cen ages do no add
o 100%.
o pa en s ei he s ongly o somewha ag eed ha accines a e
gene ally sa e, and 92·2% concu ed on hei e ec i eness. Con idence
le els in seasonal in luenza accines a ied somewha : 85·4% o
pa en s belie ed he in luenza accine o besa e, and 71·4% a es ed
o i s e ec i eness. A Like plo displaying he ange o esponses on
he a ious belie s a emen s is p o ided in Figu e1, illus a ing he
dis ibu ion o opinions among su ey esponden s.
App oxima ely 24% o pa en s exp essed hesi ancy in accina ing
hei child agains seasonal in luenza. The p ima y eason unde lying his
hesi ancy was he belie ha hei child was no a isk o con ac ing
in luenza o de eloping se e e symp oms, a iew held by nea ly hal
(47·2%) o hese hesi an pa en s. Addi ional ese a ions we e g ounded
in conce ns abou he in luenza accine’s e ec i eness (35%) and
app ehensions ega ding i s sa e y o po en ial side e ec s (29·4%). These
TABLE2 Pa en al and child seasonal in luenza accina ion his o y, u u e in en ions, and easons o accina ion.
Vaccina ion his o y and easons o accina ion N (%)1
Responding pa en equency o ecei ing an in luenza accine p io o COVID-19
E e y in luenza ( lu) season 2,475 (23·2)
Mos in luenza ( lu) seasons 2,006 (19·5)
Some in luenza ( lu) seasons (including once only) 2,818 (27·8)
Ne e 2,894 (29·5)
Responding pa en in luenza accina ion du ing he 2021–2022 in luenza season
Yes, accina ed 3,928 (37·1)
No, did no ge he accine 6,263 (62·9)
Up ake o ecommended ou ine child accina ion
Comple e 8,786 (93·3)
Pa ial 384 (4·2)
None 219 (2·4)
Child equency o ecei ing a in luenza accine p io o he COVID-19 pandemic
E e y in luenza ( lu) season 2,330 (24·3)
Mos in luenza ( lu) seasons 1,354 (14·1)
Some in luenza ( lu) seasons (including once only) 1,783 (18·5)
Ne e 3,831 (43·1)
How likely is i ha youwill ge you child accina ed agains he in luenza ( lu) in he nex in luenza ( lu) season?
De ini ely will 2,871 (26·7)
P obably will 2,455 (23·6)
P obably will no 2,264 (22·9)
De ini ely will no 1,836 (18·9)
Do no know 780 (7·9)
Reasons o child o ecei e a in luenza ( lu) accine
To p o ec hemsel es and/o household membe s om he in luenza ( lu) 2,688 (84·5)
Based on public heal h ecommenda ions 1,507 (46·1)
To p e en he sp ead o he lu in my communi y 1,594 (49·2)
The in luenza ( lu) accine was ecommended by a heal h ca e p o essional 928 (27·7)
The in luenza ( lu) accine is a ailable and ee 1,343 (40·5)
Inc eased conce ns abou lu because o he COVID-19 pandemic 914 (27·9)
My child ecei es i e e y yea 1,578 (48·9)
O he 49 (1·6)
1Pe cen weigh ed by: egion, child’s age g oup, and child’s sex a bi h.
2Mul iple esponse op ions could be selec ed by esponden s.
39
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F on ie s in Public Heal h 07 on ie sin.o g
speci ic easons o hesi ancy a e u he de ailed in Table3. While he
COVID-19 pandemic migh ha e impac ed seasonal in luenza
accina ion decisions o he 2021–2022 season, a no able majo i y
(79·7%) o pa en s epo ed ha he pandemic did no in luence hei
choice. While he pandemic se ed as a mo i a o o 10·6% o pa en s,
nea ly an iden ical pe cen age ound i o bea de e en o accina ing
hei child agains he in luenza. When examining he ba ie s ha migh
ha e p e en ed pa en s om accina ing child en agains seasonal
in luenza, he as majo i y (81%) epo ed no obs acles o accina ion.
Among he emaining pa en s who did ace challenges, he ba ie s we e
di e se. Di icul y in secu ing ime o om wo k o school was he mos
common obs acle, ci ed by 34% o hese pa en s, ollowed by hei child’s
ea o needles (24%). Financial conce ns we e ela i ely a e, wi h only
3% ci ing he cos o he accine as a ba ie . O he obs acles included
limi ed access o anspo a ion in emo e a eas (2%), language ba ie s
(0·5%), and conce ns abou acism o disc imina ion (0·9%)·.
De e minan s o non- accina ion
As de ailed in Table4, he mul i a iable logis ic eg ession models
inco po a ed a iables ha we e iden i ied as p edic o s o
non- accina ion agains seasonal in luenza in child en. Independen
p edic o s o non- accina ion included he child being in he olde age
g oup (12–17 yea s) compa ed o younge child en (less han 12 yea s
o age), esidence in u al locales a he han u ban se ings (aOR:
1·35, 95% CI: 1·13–1·60, p < 0·001), and pa en al educa ional
a ainmen below he le el o a Bachelo ’s deg ee compa ed o hose
wi h a Bachelo ’s deg ee o abo e. E hnici y o he pa en was also
ound o bea p edic o o non- accina ion, bu i s impac was no
uni o m ac oss all g oups, wi h child en o Black pa en s signi ican ly
mo e likely o benon- accina ed compa ed o child en o Whi e
Eu opean descen (aOR: 2·91, 95% CI: 1·82, 4·67, p < 0·001). Child en
in lowe household income ie s we e associa ed wi h a signi ican ly
highe odds o non- accina ion compa ed o he highes income
b acke (>$150,000): unde $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). Addi ionally, pa en s who pe cei ed he COVID-19
pandemic as a de e en o seasonal in luenza accina ion we e
conside ably mo e likely o e ain om accina ing hei child (aOR:
9·59, 95% CI: 6·04, 15·23, p < 0·001). Reasons gi en by esponden s o
hei eluc ance o accina e hei child en we e s ong p edic o s o
non- accina ion. Fo example, pa en al hesi ancy due o conce ns
abou seasonal in luenza accine e ec i eness, sa e y, and pe cei ed
isk o in ec ion we e associa ed wi h a signi ican high odds o
non- accina ion compa ed o non-hesi an pa en s (aOR: 18·78, 95%
CI: 13·03, 27·08, p < 0·001). Figu e2 p o ides a isual ep esen a ion
o he mul i a iable logis ic eg ession model’s indings, which display
he aORs and hei 95% con idence in e als o each p edic o o
seasonal in luenza non- accine.
Discussion
Using da a om a na ionally ep esen a i e sample o Canadian
pa en s/gua dians wi h child en unde 18 yea s o age, his s udy
explo es ac o s in luencing pa en al decisions o accina e child en
agains seasonal in luenza. No ably, du ing he 2021–2022 in luenza
FIGURE1
Pa en al a i udes owa d accine sa e y and e ec i eness: Like plo dis ibu ion o esponses on accine belie s a emen s1.
1Pe cen ages less han 5% a e no nume ically displayed o cla i y.
40
F on ie s in Public Heal h 01 on ie sin.o g
Spa io empo al analysis o HPV
accina ion and associa ed
neighbo hood-le el dispa i ies in
Texas—an ecological s udy
RyanRamphul
1,2*†, AbigailS.Zamo ano
3†, Saswa iUpadhyay
2,4,
ManaliDesai
1 and CiciBaue
2,5,6
1 Depa men o Epidemiology, The Uni e si y o Texas Heal h Science Cen e a Hous on School o
Public Heal h, Hous on, TX, Uni ed S a es, 2 The Join Collabo a i e on Geospa ial Analysis and Heal h,
A Collabo a ion o The Uni e si y o Texas Heal h Science Cen e a Hous on School o Public Heal h
and The Uni e si y o Texas MD Ande son Cance Cen e , Hous on, TX, Uni ed S a es, 3 Di ision o
Gynecologic Oncology, Depa men o Obs e ics, Gynecology, and Rep oduc i e Sciences, The
Uni e si y o Texas Heal h Sciences Cen e a Hous on, McGo e n Medical School, Hous on, TX,
Uni ed S a es, 4 Depa men o En i onmen al and Occupa ional Sciences, The Uni e si y o Texas
Heal h Science Cen e a Hous on School o Public Heal h, Hous on, TX, Uni ed S a es, 5 Depa men
o Bios a is ics and Da a Science, The Uni e si y o Texas Heal h Science Cen e a Hous on School o
Public Heal h, Hous on, TX, Uni ed S a es, 6 Cen e o Spa ial-Tempo al Modeling o Applica ions in
Popula ion Sciences, Uni e si y o Texas Heal h Science Cen e a Hous on School o Public Heal h,
Hous on, TX, Uni ed S a es
Backg ound: HPV is esponsible o mos ce ical, o opha yngeal, anal, aginal,
and ul a cance s. The HPV accine has dec eased ce ical cance incidence,
bu only 49% o Texas adolescen s ha e ini ia ed he accine. Texas shows g ea
a ia ion in HPV accina ion a es. Weused geospa ial analysis o iden i y a eas
wi h high and low accina ion a es and explo ed di e ences in neighbo hood
cha ac e is ics.
Me hods: Using Anselin’s Local Mo an’s Is a is ic, weconduc ed an ecological
analysis o ho and cold spo s o adolescen HPV accina ion co e age in
Texas om 2017 o 2021. Nex , weu ilized a Mann–Whi ney U es o compa e
neighbo hood cha ac e is ics o accina ion co e age in ho spo s e sus cold
spo s, le e aging da a om he Child Oppo uni y Index (COI) and Ame ican
Communi y Su ey.
Resul s: In Texas, he e a e 64 pe sis en accina ion co e age ho spo s and 55
pe sis en accina ion co e age cold spo s. The pe sis en accina ion co e age
ho spo s a e cha ac e ized by ZIP codes wi h lowe COI sco es, highe
pe cen ages o Hispanic esiden s, highe po e y a es, and smalle popula ions
pe squa e mile compa ed o accine co e age cold spo s. We ound a mo e
p onounced spa ial clus e ing pa e n o male adolescen accine co e age
han wedid o emale adolescen accine co e age.
Conclusion: In Texas, HPV accina ion co e age a es di e depending on he
communi y’s income le el, wi h lowe -income a eas achie ing highe success
a es. No ably, he e a e also gende -based disc epancies in accina ion
co e age a es, pa icula ly among male adolescen s. This knowledge can aid
ad oca es in cus omizing hei ou each ini ia i es o add ess hese dispa i ies.
KEYWORDS
spa ial analysis, HPV accina ion, accina ion dispa i ies, cance p e en ion, mino i y
heal h, HPV, geospa ial analysis, heal h ca e dispa i ies
OPEN ACCESS
EDITED BY
Ca los Albe o De Oli ei a Magalhães Júnio ,
S a e Uni e si y o Ma ingá, B azil
REVIEWED BY
Gab iela Bus aman e,
Uni e sidad San F ancisco de Qui o, Ecuado
Nobila Jean Ma c Oued aogo,
Ge man Cance Resea ch Cen e (DKFZ),
Ge many
*CORRESPONDENCE
Ryan Ramphul
[email p o ec ed]
†These au ho s ha e con ibu ed equally o
his wo k and sha e i s au ho ship
RECEIVED 16 Ap il 2024
ACCEPTED 06 June 2024
PUBLISHED 25 June 2024
CITATION
Ramphul R, Zamo ano AS, Upadhyay S,
Desai M and Baue C (2024) Spa io empo al
analysis o HPV accina ion and associa ed
neighbo hood-le el dispa i ies in Texas—an
ecological s udy.
F on . Public Heal h 12:1418526.
doi: 10.3389/ pubh.2024.1418526
COPYRIGHT
© 2024 Ramphul, Zamo ano, Upadhyay,
Desai and Baue . This is an open-access
a icle dis ibu ed unde he e ms o he
C ea i e Commons A ibu ion License
(CC BY). The use, dis ibu ion o ep oduc ion
in o he o ums is pe mi ed, p o ided he
o iginal au ho (s) and he copy igh owne (s)
a e c edi ed and ha he o iginal publica ion
in his jou nal is ci ed, in acco dance wi h
accep ed academic p ac ice. No use,
dis ibu ion o ep oduc ion is pe mi ed
which does no comply wi h hese e ms.
TYPE O iginal Resea ch
PUBLISHED 25 June 2024
DOI 10.3389/ pubh.2024.1418526
47
Ramphul e al. 10.3389/ pubh.2024.1418526
F on ie s in Public Heal h 02 on ie sin.o g
In oduc ion
Human papilloma i us (HPV) accoun s o o e 99% o ce ical
cance s and mos o opha yngeal, anal, aginal, and ul a cance
(1, 2). Mo e han 90% o HPV-associa ed cance s a e p e en able
h ough HPV accina ion (3), which is ecommended as a ou ine
accina ion o child en as ea ly as age 9, wi h ca ch-up ecommended
up o age 26 o hose no p e iously accina ed and up o age 45 using
sha ed clinical decision-making (4). Since he in oduc ion o he
HPV accine in 2006, he e has al eady been a signi ican decline in
na ionwide ce ical cance incidence, especially in he 15–20-yea age
g oup, sugges ing he posi i e impac o accina ion (5). Howe e , he
Uni edS a es alls well behind i s Heal hy People 2020 a ge o 80%
accina ed adolescen s, wi h only 54.5% comple ing he se ies (6, 7).
As o 2017, only 49% o adolescen s in Texas had ini ia ed he
HPV accine se ies, and he s a e anks 47 ou o 50in accina ion
a es na ionwide (8). Vaccina ion a es ac oss he s a e a e no
geog aphically uni o m, wi h some u al coun ies ou pe o ming he
majo ci ies and he es o he s a es (8, 9). While p e ious s udies
ha e demons a ed his egional a ia ion, hey ha e been limi ed o
analyses o la ge s a e egions, which makes u he analysis o
associa ed sociodemog aphic ac o s incomple e.
Geospa ial analyses o HPV accina ion ha e been c ucial o
iden i y dispa i ies and a ge a eas o in e en ion. A sys ema ic
e iew o a ea-le el a ia ion in HPV accina ion up ake e ealed
signi ican di e ences in luenced by socioeconomic ac o s, heal hca e
access, and educa ional a ainmen (10). Fo example, egions wi h
highe po e y a es and lowe access o heal hca e se ices o en
exhibi lowe accina ion a es. Con e sely, a eas wi h obus public
heal h in as uc u es and a ge ed educa ion campaigns end o
achie e highe accina ion co e age. These indings emphasize he
need o localized public heal h s a egies conside ing hese
sociodemog aphic ac o s. By unde s anding he speci ic
cha ac e is ics and ba ie s in di e en egions, public heal h
ini ia i es can bebe e ailo ed o imp o e HPV accina ion a es
e ec i ely (10, 11). Such de ailed geospa ial and sociodemog aphic
analyses can help b idge he gaps in HPV accina ion co e age,
ensu ing mo e uni o m p o ec ion agains HPV-associa ed cance s
ac oss di e se communi ies.
Signi ican ba ie s o HPV accina ion exis , including lack o
knowledge o he accine o he associa ed cance s, lack o access o
immuniza ion (in ol ing geog aphic, inancial, and public policy
ac o s), lack o p o ide ecommenda ion, and pa en al hesi a ions
abou accep ing he accine o child en/adolescen s due o he
associa ion wi h a sexually ansmi ed in ec ion (12). Weaim o
geospa ially model a eas o Texas wi h pe sis en ly high o low le els
o HPV accina ion co e age o be e unde s and he associa ed a ea-
le el cha ac e is ics and iden i y a eas whe e inc eased accina ion
e o s may bepu sued.
Me hods
S udy popula ion
Da a we e ob ained h ough he Texas Depa men o S a e Heal h
Se ices Immuniza ion In o ma ion Sys em (ImmT ac2) Regis y (13)
on he pe cen age o egis an s aged 9+ who ecei ed a leas one dose
o he HPV accine, ca ego ized by ZIP code, o each yea om 2017
o 2021. I also p o ided sepa a e pe cen age es ima es o male and
emale egis an s aged 9+ who ecei ed a leas one dose by ZIP o
each yea om 2017–2021. ImmT ac2 is a s a e-wide op -in accine
egis y and includes in o ma ion p o ided by heal hca e p o ide s,
pha macies, public heal h clinics, Medicaid claims adminis a o s, and
he Texas Depa men o S a e Heal h Se ices Vi al S a is ics Uni .
While i con ains in o ma ion o bo h child en and adul s, mos
child en a e en e ed in o he sys em a bi h, while adul s o e 18 mus
consen o pa icipa e o con inue pa icipa ion. Addi ionally,
accina ions gi en o child en mus be epo ed by law (13). As a
esul , he ImmT ac2 egis y is p edominan ly aluable as a da abase
o accina ions o childhood and adolescence. ImmT ac2 op -in
immuniza ion egis y equi es pa en al consen o s o e child en’s
accina ion eco ds. While Texas law manda es heal hca e p o ide s
o epo all immuniza ions gi en o child en unde 18 o ImmT ac2,
including hese eco ds in he egis y elies on ob aining pa en al o
gua dian consen . I consen is p o ided, he accina ion in o ma ion
is s o ed; o he wise, i is no , al hough he p o ide s ill mee s he legal
epo ing equi emen . The exac pe cen age o childhood
accina ions epo ed o ImmT ac2 a ies based on consen a es, bu
manda o y epo ing ensu es a high o e all epo ing a e despi e he
lack o p ecise igu es (13). In 2020, 80% o Texas child en unde
6 yea s old had a leas wo immuniza ions eco ded in ImmT ac2 (14),
indica ing ImmT ac2’s obus co e age o pedia ic popula ions.
Da a in his s udy was publicly a ailable and ecei ed an
exemp ion om Ins i u ional Re iew Boa d (IRB) app o al.
Mapping and s a is ical analysis
We u ilized Anselin’s Local Mo an’s Is a is ic, pionee ed by Luc
Anselin in he “Local Indica o s o Spa ial Associa ion—LISA,” o
iden i y s a is ically signi ican clus e s o ZIP codes wi h high/low
es ima ed a es o HPV accina ion co e age each yea om 2017 o
2021 (15). Using he En i onmen al Science Resea ch Ins i u e’s
A cGIS P o Ve sion 2.2.0 so wa e, we an he Clus e and Ou lie
Analysis Tool, which implemen s he Local Mo an’s Is a is ic by i s
de e mining a “neighbo hood” a ound each ZIP code in he da ase
(16). While se e al s a egies exis o de e mine he “neighbo hood”
a ound each ZIP code, weused he Queen Con igui y Me hod. In his
me hod, all ZIP codes ha ouch a ZIP code a e conside ed i s
“neighbo hood” and a e included in i s compu a ions (17). The Queen
Con igui y Me hod has been success ully used in se e al s udies o
iden i y heal h ou comes and se ice clus e s (17).
A e de e mining he neighbo hoods a ound each ZIP code, he
Clus e and Ou lie Analysis Tool calcula es a Local Mo an’s Isco e
o each ZIP code, whe e a posi i e alue o “I” indica es ha a ZIP
code has a neighbo ing ZIP code wi h simila ly high o low
accina ion a es compa ed o he es o he s udy a ea (16). These
ZIP codes a e pa o clus e s. A e calcula ing a Local Mo an’s I o
each ZIP code in he da a se , s a is ical signi icance is es ed by
unning a Mon e Ca lo simula ion. The alues in he “neighbo hoods”
a ound each ZIP in he s udy a ea a e andomly ea anged 9,999
imes. A Local Mo an’s Isco e is calcula ed each ime, c ea ing a
andom e e ence dis ibu ion o Local Mo an’s I o compa e wi h he
obse ed Local Mo an’s I. A pseudo-p- alue is hen calcula ed by
de e mining he p opo ion o Local Mo an’s Is a is ics gene a ed
48
Ramphul e al. 10.3389/ pubh.2024.1418526
F on ie s in Public Heal h 03 on ie sin.o g
om andom pe mu a ions ha display mo e clus e ing han he
o iginal da a. I he p opo ion is less han 0.05, he ZIP code is
dema ca ed as a s a is ically signi ican accina ion co e age ho o
cold spo (16). Pe sis en accina ion co e age in ho and cold spo s
we e de ined as ZIP codes ha consis en ly exhibi ed s a is ically
signi ican high o low accina ion co e age a es o e i e consecu i e
yea s, espec i ely.
Finally, weu ilized a Mann–Whi ney U es o explo e s a is ical
di e ences in neighbo hood cha ac e is ics be ween ZIP codes ha
we e pe sis en accina ion co e age ho o cold spo s o all
egis an s aged 9+ and hen by male and emale egis an s. Median
pe cen ages o neighbo hood cha ac e is ics (e.g., % Black, % below
he ede al po e y le el, e c.) we e chosen as he measu e o he
cen e ins ead o he mean because i is less a ec ed by ex eme
alues and skewed dis ibu ions. This p o ides a mo e accu a e
ep esen a ion o he cen al endency in ou da ase , whe e
a iables like income and popula ion densi y exhibi signi ican
skewness. S a is ical analyses we e pe o med in SPSS e sion
28.01.1.
Neighbo hood e alua ion me ics
The Child Oppo uni y Index (COI) and he U.S. Census Bu eau’s
Ame ican Communi y Su ey (ACS) we e used o desc ibe
neighbo hood cha ac e is ics (18, 19). The COI is a alida ed
composi e index o measu e neighbo hood esou ces and condi ions.
I consis s o 29 social de e minan s o heal h (SDOH) indica o s o
neighbo hood-based oppo uni ies, including high-quali y schools,
g een space, heal hy ood, oxin- ee en i onmen s, and
socioeconomic esou ces (18). COI indica o s a e assigned indi idual
z-sco es and summed o an o e all z-sco e using indica o -speci ic
weigh s ha signi y how s ongly each indica o p edic s child en’s
heal h and economic ou comes. Weused he mos ecen e sion o
his da a, which was om 2015. The COI indica o s a e di ided in o
h ee subdomains: Educa ion, Heal h and En i onmen , and Social
and Economic. ZIP codes a e sco ed as a e y low oppo uni y, low
oppo uni y, mode a e oppo uni y, high oppo uni y, o e y high
oppo uni y wi hin each domain (18).
The ACS is he U.S. Census Bu eau’s la ges household su ey and
p o ides ZIP code le el es ima es o po e y le els, acial/e hnic
di e si y, insu ance co e age, and popula ion densi y (19). Weused
he mos ecen ly published da a (2016–2020), which gi es an a e age
es ima e o he cha ac e is ics o e he 60-mon h pe iod. Finally,
wecondensed ZIP code le el Ru al–U ban Commu ing A ea (RUCA)
codes (20) in o ou ca ego ies (u ban- ocused, la ge u al ci y, small
u al own, and isola ed small u al own) as discussed by he Ru al
Heal h Resea ch Cen e .
Resul s
The a e age pe cen o egis an s (aged 9+) by ZIP code in Texas’s
ImmT ac2 da abase who ecei ed a leas one dose o he HPV accine
emained ela i ely simila om 2017 o 2021, hough ended sligh ly
downwa d o e he 5 yea s (Figu e1). The a e age pe cen age anged
be ween 21 and 23%. A e age accina ion a es by ZIP o e his i e-
yea pe iod we e highe o emale adolescen s han male adolescen s,
which aligns wi h end da a om he CDC’s Na ional Immuniza ion
Su eys (11).
Among he 1,800+ ZIP codes in Texas, weiden i ied 64 ZIP codes
ha we e s a is ically signi ican ho spo s o HPV accina ion
co e age 5 yea s in a ow and 55 ZIP codes ha we e cold spo s o
accina ion co e age 5 yea s in a ow. As illus a ed in Figu es2, 3, he
pe sis en accina ion co e age ho spo s we e p ima ily nea he
sou he n Gul coas , he no hwes e n po ion o he s a e, and close
o El Paso. Cold spo s we e p ima ily loca ed in he cen al po ion o
he s a e, he panhandle, and in pa s o majo u ban a eas like
Hous on and Dallas. Howe e , on close inspec ion o he majo ci ies
o Dallas and Hous on, he e a e signi ican di e ences in hese
densely popula ed a eas, wi h he cold spo s in he u ban and
subu ban weal hie a eas and he ho spo s in sou heas Dallas and
no heas Hous on, which a e ypically lowe income. The emainde
o he ZIP codes in he s a e we e no pa o s a is ically signi ican
clus e s 5 yea s in a ow o we e ou lie s.
When e alua ing di e ences in HPV accina ion by epo ed
gende , we ound 55 ho spo ZIP codes and 38 cold spo ZIP codes
among male adolescen s alone. These we e in a eas simila o o e all
ho /cold spo s. Howe e , among emale adolescen s alone,
weiden i ied jus 11 ho spo ZIP codes o HPV accina ion and 13
cold spo ZIP codes. These we e also loca ed in a eas like o e all ho /
cold spo s ( igu es by gende no shown).
Demog aphic analysis o pe sis en ho
spo and cold spo ZIPs
We ound ha pe sis en ho spo ZIP codes o HPV accina ion
co e age had signi ican ly lowe o e all COI sco es, indica ing lowe
oppo uni y a eas han pe sis en cold spo ZIP codes (o e all median
sco e 2 s. 4, p < 0.001, Table1). As seen in Figu e2, Tempo al changes
in bo h accina ion ho spo s and cold spo s we e iden i ied. O e
ime, ho spo s on he bo om pa o he sou he n Gul Coas
expanded, whe eas he no hwes e n po ion has dec eased. Cold
spo s, especially in he panhandle, expanded o e ime. O e all,
spa ial pa e ns we e qui e simila . This di e ence pe sis ed in each
subdomain (Educa ion, Heal h, En i onmen , and Social and
Economic) and when each was b oken ou by gende (Table1).
As shown in Table2, using Ame ican Communi y Su ey (ACS)
da a, pe sis en ho spo ZIPs had a highe median pe cen age o he
popula ion below he ede al po e y le el (17.40% s. 7.14%,
p < 0.001). Pe sis en ho spo s also had highe a es o esiden
child en who a e ei he uninsu ed (2.87% s. 1.92%, p < 0.001) o on
public insu ance (11.75% s. 2.91%, p < 0.001) han pe sis en cold
spo s. Cold spo ZIPs had s a is ically highe pe cen ages o child en
on p i a e insu ance plans (12.3% s. 8.6%) (p = 0.001). The e we e
signi ican ly highe a es o Hispanic esiden s in ho spo ZIPs
compa ed o cold spo ZIPs (53.32% s. 20.65%, p < 0.001) and lowe
pe cen ages o Asian esiden s (0.89% s. 8.28%, p < 0.001). Pe sis en
ho spo ZIPs did ha e a s a is ically highe a e o Caucasian esiden s
han pe sis en cold spo s, bu his did no pe sis when b oken ou by
gende . The e was no di e ence in he pe cen age o Black esiden s
o e all o by gende be ween ho and cold spo s. Ho spo ZIPs had
lowe median popula ions pe squa e mile (29.00 s. 2287.80,
p < 0.001). S ill, he e was no di e ence in u al/u ban designa ion by
RUCA code, wi h he majo i y being u ban- ocused.
49
Ramphul e al. 10.3389/ pubh.2024.1418526
F on ie s in Public Heal h 04 on ie sin.o g
Discussion
This s udy ound signi ican geog aphic, gende , and
socioeconomic dispa i ies be ween pe sis en ho spo s and pe sis en
cold spo s o HPV accina ion co e age in Texas. Pe sis en ho spo s
a e mo e likely o bedisad an aged neighbo hoods, wi h lowe Child
Oppo uni y Index sco es and subdomain sco es, highe po e y a es,
lowe median household incomes, and g ea e pe cen ages o child en
on public insu ance o uninsu ed. They a e also gene ally less densely
popula ed han pe sis en cold spo s and ha e highe pe cen ages o
Hispanic esiden s. Pe sis en cold spo s o HPV accina ion, on he
o he hand, ha e signi ican ly highe a es o Asian esiden s and a e
mo e densely popula ed. This inding aligns wi h s udies documen ing
a “ e e se dispa i y” in HPV accina ion, wi h highe a es among
ce ain acial mino i ies and hose ecei ing public insu ance (21). I
has been hypo hesized, o example, ha he El Paso egion o Texas
has such a high accina ion a e due o he pe cei ed inc eased isk o
HPV- ela ed cance s in he communi y, leading o g ea e olun a y
accina ion up ake (22). The e also may bemo e obus p o ide
ecommenda ions and accine ou each in a eas pe cei ed as a highe
isk o HPV- ela ed cance s. Ou s udy a i ms his e e se dispa i y
among much o Texas bu sugges s ha some unde ep esen ed
FIGURE1
A e age pe cen o egis an s (aged 9+) by ZIP in ImmT ac2, who ecei ed a leas one dose o he HPV accine in Texas.
FIGURE2
HPV accina ion ho and cold spo s in Texas.
50
Ramphul e al. 10.3389/ pubh.2024.1418526
F on ie s in Public Heal h 05 on ie sin.o g
mino i y popula ions, no ably communi ies o Asian esiden s in
u ban loca ions, may bene i om u he analysis.
Compa ing ou esul s wi h s udies om o he s a es, weobse e
bo h simila i ies and di e ences. In New Yo k, highe HPV
accina ion a es ha e been epo ed among Hispanic and Black
adolescen s, aligning wi h ou indings in Texas (23). Howe e , hese
s a es did no exhibi he same ex en o e e se dispa i y o male
adolescen s, sugges ing ha local cul u al, socioeconomic, and policy
ac o s migh in luence hese pa e ns (23, 24). Fo ins ance, he s udy
“Imp o ing HPV Vaccina ion Ra es in a Racially and E hnically
Di e se Pedia ic Popula ion” highligh ed success ul in e en ions
ha inc eased accina ion a es in a di e se popula ion ye did no
epo signi ican gende dispa i ies like hose ound in Texas (24).
These di e ences unde sco e he impo ance o conside ing local
con ex and ailo ed in e en ions when add essing HPV accina ion
dispa i ies ac oss di e en egions.
Se e al s udies ha e obse ed a e e se dispa i y in HPV
accina ion a es among Hispanic communi ies, simila o ends seen
in ce ical cance sc eening. Fo ins ance, esea ch has shown ha
Hispanic adolescen s ha e highe HPV accina ion a es compa ed o
hei non-Hispanic whi e coun e pa s, likely due o a ge ed public
heal h ini ia i es and communi y ou each p og ams (25). Simila ly,
in many s a es, Hispanic women cons i u e a signi ican p opo ion o
he clien s se ed by he Na ional B eas and Ce ical Cance Ea ly
De ec ion P og am (NBCCEDP), indica ing e ec i e ou each and
u iliza ion o se ices wi hin his communi y (24). S udies ha e also
FIGURE3
Pe sis en ho /cold spo ZIP codes o HPV accina ion in Texas, 2017–2021.
51
Ramphul e al. 10.3389/ pubh.2024.1418526
F on ie s in Public Heal h 06 on ie sin.o g
epo ed highe ce ical cance sc eening a es among Hispanic
women, a ibu ed o cul u ally ailo ed in e en ions and communi y
heal h p og ams ha add ess language ba ie s and p o ide pa ien
na iga ion (26). These indings unde sco e he impo ance o
cul u ally sensi i e heal hca e in e en ions in imp o ing p e en i e
heal h measu es in Hispanic communi ies. Howe e , add essing
dispa i ies in ollow-up ca e and ea men emains c i ical o ensu e
comp ehensi e ca e o hese popula ions.
Rega ding cha ac e is ics o pe sis en ho spo ZIP codes o HPV
accina ion co e age, such as highe a es o child en on Medicaid
insu ance and lowe a es on p i a e insu ance plans, his may
be ep esen a i e o he gene al socioeconomic makeup o he
TABLE1 Child oppo uni y index sco e analysis o pe sis en ho and cold spo ZIPs o HPV accina ion.
Child oppo uni y index
domains†
Pe sis en ho spo s Pe sis en cold spo s p- alue*
Child oppo uni y index sco e, o e all (median
sco e)
2.0 4.0 <0.001
Males aged 9+ 2.0 4.0 <0.001
Females aged 9+ 3.0 5.0 0.003
Educa ion domain (median sco e) 2.0 5.0 <0.001
Males aged 9+ 2.0 3.5 <0.001
Females aged 9+ 3.0 5.0 0.009
Heal h and en i onmen domain (median
sco e)
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 sco e) 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, e y low oppo uni y; 2, low oppo uni y; 3, mode a e oppo uni y; 5, high oppo uni y; 6, e y high oppo uni y. *Mann–Whi ney U Tes Signi icance Le el (0.05). Bold ex indica e
s a is ically signi ican alues.
TABLE2 Demog aphic and socioeconomic cha ac e is ics o pe sis en ho spo s and cold spo s.
ZIP code le el cha ac e is ics Pe sis en ho spo s Pe sis en cold spo s p- alue*
Income
Popula ion below he ede al po e y le el
(pe cen age, 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/E hnici y
(pe cen age, 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
A ican Ame ican 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
(Con inued)
52
Ramphul e al. 10.3389/ pubh.2024.1418526
F on ie s in Public Heal h 07 on ie sin.o g
communi ies (i.e., lowe median household income). Howe e , his
may also bedue o accina ion bene i s among ede ally sponso ed
insu ance, no ably he Vaccines o Child en p og am, which p o ides
he HPV accine a no cos o hose who mee eligibili y c i e ia
(Medicaid o uninsu ed). The e lec ion on how p i a e insu ance may
de e accina ion wa an s a deepe discussion. P i a e insu ance plans
o en ha e highe co-pays and deduc ibles compa ed o public
insu ance, which can discou age amilies om comple ing he HPV
accina ion se ies. S udies ha e shown ha indi iduals wi h public
insu ance o who a e uninsu ed a e mo e likely o ecei e accina ions
h ough public heal h p og ams, which o en co e he ull cos o
accines (27). This inancial ba ie associa ed wi h p i a e insu ance
plans may con ibu e o lowe accina ion a es among insu ed
indi iduals, highligh ing he need o policy in e en ions o educe
ou -o -pocke accina ion cos s. Mo e esea ch is needed o unde s and
he ba ie s o HPV accina ion among all popula ions, bu co e age
o all people, ega dless o insu ance s a us, should bep io i ized.
Impo an ly, ou s udy highligh s di e ences in adolescen HPV
accina ion co e age ho spo s among male adolescen s e sus emale
adolescen s. The e we e many mo e ho and cold spo s o HPV
accina ion co e age among male adolescen s, indica ing mo e
clus e s o a eas wi h high HPV accina ion co e age a es and low
accina ion co e age a es. This sugges s ha ac oss he s a e, HPV
accina ions a e mo e widesp ead among emale adolescen s
compa ed o male adolescen s. Inc easing accina ion s a egies
speci ically a ge ing male adolescen s, he e o e, may bewa an ed.
Ou s udy does ha e some limi a ions. P ima ily, ou da a is
om he ImmT ac2 sys em, an op -in p og am ha may no
en i ely ep esen he popula ion. Addi ionally, he use o he ACS
and COI da a as popula ion-based me ics may no
be ep esen a i e o he indi iduals ecei ing he accines.
Wewe e unable o ob ain mo e speci ic demog aphic in o ma ion
on pa icipan s, which limi s he analysis o an ecological
app oach (8). Finally, he e is a no able disc epancy be ween ou
epo ed adolescen HPV accina ion co e age a es (21–23%)
and hose epo ed in he Nehme a icle o (30–40%) (8), which
ci ed highe a es o Texas. This is because he Nehme a icle
used da a om he Na ional Immuniza ion Su ey-Teen (NIS-
Teen). NIS-Teen is a andom digi dialing elephone su ey o
households in he U.S. plus p o ide - epo ed accina ion
his o ies o eens whose pa en s pa icipa e in he phone su ey
and consen o ha ing hei een’s accina ion p o ide s con ac ed.
While NIS-Teen da a o e s comp ehensi e and ep esen a i e
accina ion co e age es ima es, i elies on sample-based
es ima es. Con e sely, ImmT ac2 p o ides de ailed and imely
immuniza ion eco ds, bene icial o moni o ing and p og am
e alua ion, bu i s op -in na u e leads o unde ep esen a ion and
a iable pa icipa ion, as i equi es pa en al consen o mino s,
esul ing in incomple e da a. None heless, ImmT ac2 main ains
obus co e age o accines gi en o pedia ic popula ions (14).
To ou knowledge, his is he i s spa io empo al analysis o HPV
accina ion co e age in Texas. Modeling s a is ical ho spo s o HPV
accina ion and iden i ying ZIP codes ha model as ho /cold spo s
5 yea s in a ow p esen s a ho ough app oach o unde s a ing HPV
accina ion geog aphically in Texas. Few s udies on HPV accina ions
u ilize high spa ial esolu ion da a, like ZIP codes, which allow o
in eg a ing neighbo hood-le el da a like he Child Oppo uni y Index
and key Ame ican Communi y Su ey a iables. These da a sou ces
allow a be e unde s anding o neighbo hood con ex , which may
a ec accina ion beha io s. Unde s anding he spa io empo al
dynamics o HPV accina ion a es in a as s a e like Texas can enable
ad oca es o ailo messaging and ou each mo e e ec i ely o
p omo e accine up ake.
Da a a ailabili y s a emen
Publicly a ailable da ase s we e analyzed in his s udy. This
da a can be ound a : h ps://www.dshs. exas.go /immuniza ions/
TABLE2 (Con inued)
ZIP code le el cha ac e is ics Pe sis en ho spo s Pe sis en cold spo s p- alue*
Insu ance co e age o child en
(pe cen age, 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
P i a e 8.2 12.3 0.001
Males aged 9+ 7.9 9.9 0.029
Females aged 9+ 11.1 13.5 0.277
Uninsu ed 2.9 1.9 <0.001
Males aged 9+ 3.1 1.9 0.009
Females aged 9+ 3.02 1.9 0.150
Popula ion densi y
Popula ion pe squa e 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 esul )‡U ban- ocused U ban- ocused 0.445
Males aged 9+ U ban- ocused U ban- ocused 0.124
Females aged 9+ U ban- ocused U ban- ocused 0.649
*Mann–Whi ney U Tes Signi icance Le el (0.05). ‡Ca ego ized in o ou domains: U ban- ocused, La ge u al ci y, Small u al own, and Isola ed u al. Bold ex indica e s a is ically signi ican alues.
53
Ramphul e al. 10.3389/ pubh.2024.1418526
F on ie s in Public Heal h 08 on ie sin.o g
wha -we-do/p og ams; h ps://da a.di e si yda akids.o g/da ase /
coi30-2010- ac s-child-oppo uni y-index-3-0-da abase--2010-
census- ac s?_ga=2.105088003.1687438952.1713278005-6079392.
1713278005
Au ho con ibu ions
RR: Concep ualiza ion, Da a cu a ion, Fo mal analysis, Funding
acquisi ion, Me hodology, Resou ces, So wa e, Supe ision,
Visualiza ion, W i ing – o iginal d a , W i ing – e iew & edi ing. AZ:
Concep ualiza ion, Da a cu a ion, Fo mal analysis, In es iga ion,
P ojec adminis a ion, Resou ces, Supe ision, W i ing – o iginal
d a , W i ing – e iew & edi ing. SU: P ojec adminis a ion, W i ing
– o iginal d a , W i ing – e iew & edi ing. MD: Da a cu a ion,
In es iga ion, Me hodology, W i ing – e iew & edi ing. CB: Fo mal
analysis, Funding acquisi ion, Me hodology, Resou ces, Valida ion,
W i ing – e iew & edi ing.
Funding
The au ho (s) decla e ha no inancial suppo was ecei ed o
he esea ch, au ho ship, and/o publica ion o his a icle.
Acknowledgmen s
The Join Cen e on Geospa ial Analysis and Heal h, A
Collabo a ion o The Uni e si y o Texas Heal h Science Cen e a
Hous on School o Public Heal h and The Uni e si y o Texas MD
Ande son Cance Cen e , made possible by UTHeal h Academic
Excellence Endowmen and dono s o he Uni e si y o Texas MD
Ande son Cance Cen e ’s Annual Fund.
Con lic o in e es
The au ho s decla e ha he esea ch was conduc ed wi hou any
comme cial o inancial ela ionships ha could po en ially c ea e a
con lic o in e es .
Publishe ’s no e
All claims exp essed in his a icle a e solely hose o he au ho s
and do no necessa ily ep esen hose o hei a ilia ed o ganiza ions,
o hose o he publishe , he edi o s and he e iewe s. Any p oduc
ha may bee alua ed in his a icle, o claim ha may bemade by i s
manu ac u e , is no gua an eed o endo sed by he publishe .
Re e ences
1. HPV and Cance . (2023). A ailable a : h ps://www.cance .go /abou -cance /
causes-p e en ion/ isk/in ec ious-agen s/hp -and-cance .
2. Sa aiya M, Unge ER, Thompson TD, Lynch CF, He nandez BY, Lyu CW, e al. US
assessmen o HPV ypes in cance s: implica ions o cu en and 9- alen HPV
accines. J Na l Cance Ins . (2015) 107:dj 086. doi: 10.1093/jnci/dj 086
3. Cance s Caused by HPV A e P e en able. Human papilloma i us. (2021). A ailable
a : h ps://www.cdc.go /hp /hcp/p o ec ing-pa ien s.h ml.
4. Mei es E, Szilagyi PG, Chesson HW, Unge ER, Rome o JR, Ma kowi z LE. Human
papilloma i us accina ion o adul s: upda ed ecommenda ions o he ad iso y
commi ee on immuniza ion p ac ices. MMWR Mo b Mo al Wkly Rep. (2019)
68:698–702. doi: 10.15585/mmw .mm6832a3
5. Mix JM, Van Dyne EA, Sa aiya M, Hallowell BD, Thomas CC. Assessing impac o
HPV Vaccina ion on ce ical cance incidence among women aged 15-29 yea s in he
Uni edS a es, 1999-2017: an ecologic s udy. Cance Epidemiol Bioma ke s P e . (2021)
30:30–7. doi: 10.1158/1055-9965.EPI-20-0846
6. HPV accina ion: online summa y o ends in US cance con ol measu es (2022).
A ailable a : h ps://p og ess epo .cance .go /p e en ion/hp _immuniza ion.
7. Chen S, Huyb ech s KF, Ba eman BT, He nández-Díaz S. T ends in human
papilloma i us Vaccina ion in comme cially insu ed child en in he Uni edS a es.
Pedia ics. (2020) 146:e20193557. doi: 10.1542/peds.2019-3557
8. Nehme EPD, Oppenheime D, Ka imi a M, Ele ian N, Lakey D. Missed
oppo uni y: human papilloma i us in Texas. Aus in, TX: Texas Heal h Jou nal (2017).
9. Con ey R, Valencia V, Ciole i A, Williams-B own MY. Regional a ia ion in human
papilloma i us accina ion up ake and comple ion among adolescen s 13-17in he s a e
o Texas. Vaccine. (2020) 38:4119–24. doi: 10.1016/j. accine.2020.03.059
10. Do EK, Rossi B, Mille CA, Ksinan AJ, Wheele DC, Chukmai o A, e al. A ea-
le el a ia ion and human papilloma i us accina ion among adolescen s and young
adul s in he Uni edS a es: a sys ema ic e iew. Cance Epidemiol Bioma ke s P e .
(2021) 30:13–21. doi: 10.1158/1055-9965.EPI-20-0617
11. Pingali C, Yankey D, Elam-E ans DL, Ma kowi z EL, Valie MR, F edua B, e al.
Vaccina ion co e age among adolescen s aged 13-17 yea s- Na ional Immuniza ion
Su ey-Teen, Uni edS a es, 2022. MMWR Mo b Mo al Wkly Rep. (2022) 72:912–9. doi:
10.15585/mmw .mm7234a3
12. Teoh D, Hill EK, Goldsbe y W, Le ine L, No e sky A, Downs LJ. O e coming he
ba ie s o HPV accina ion in high- isk popula ions in he U.S.: a Socie y o
Gynecologic Oncology (SGO) e iew. Gynecol Oncol. (2021) 161:228–35. doi: 10.1016/j.
ygyno.2021.01.023
13. Texas Immuniza ion Regis y (2022). h ps://www.dshs. exas.go /immuniza ions/
wha -we-do/p og ams
14. Un angling ImmT ac2: TMA aims o build on immuniza ion egis y e o ms.
(2022). A ailable a : h ps://www. exmed.o g/Templa e.aspx?id=60086.
15. Anselin L. Local indica o s o spa ial associa ion—LISA. Geog Anal. (1995)
27:93–115. doi: 10.1111/j.1538-4632.1995. b00338.x
16. Clus e and ou lie analysis (Anselin Local Mo an's I) (spa ial s a is ics). A ailable
a : h ps://p o.a cgis.com/en/p o-app/la es / ool- e e ence/spa ial-s a is ics/clus e -and-
ou lie -analysis-anselin-local-mo an-s.h m.
17. Modeling Spa ial Rela ionships. A ailable a : h ps://p o.a cgis.com/en/p o-app/
la es / ool- e e ence/spa ial-s a is ics/modeling-spa ial- ela ionships.h m.
18. Ace edo-Ga cia D, McA dle N, Ha dy EF, C isan UI, Romano B, No is D, e al.
The child oppo uni y index: imp o ing collabo a ion be ween communi y de elopmen
and public heal h. Heal h A . (2014) 33:1948–57. doi: 10.1377/hl ha .2014.0679
19. Ame ican Communi y Su ey (ACS) (2022). A ailable a : h ps://www.census.go /
p og ams-su eys/acs.
20. Ru al-U ban Commu ing A ea Codes. A ailable a : h ps://www.e s.usda.go /
da a-p oduc s/ u al-u ban-commu ing-a ea-codes/
21. Spence JC, Calo WA, B ewe NT. Dispa i ies and e e se dispa i ies in HPV
accina ion: a sys ema ic e iew and me a-analysis. P e Med. (2019) 123:197–203. doi:
10.1016/j.ypmed.2019.03.037
22. F ie ze G, Padilla M, Co de o J, Gosselink K, Moya E. Human papilloma i us
accine accep ance (HPV-VA) and accine up ake (HPV-VU): assessing he impac o
heo y, cul u e, and us ed sou ces o in o ma ion in a Hispanic communi y. BMC
Public Heal h. (2023) 23:1781–1. doi: 10.1186/s12889-023-16628-1
23. NYS Heal h Founda ion. Making P og ess on HPV Vaccina ion in New Yo k S a e
(2022). A ailable a : h ps://nyheal h ounda ion.o g/wp-con en /uploads/2022/03/
making-p og ess-on-HPV- accina ion-new-yo k-s a e.pd
24. Cox JE, Boga LM, Ellio MN, S a me AJ, Meleedy-Rey P, Goggin K, e al.
Imp o ing HPV Vaccina ion a es in a acially and e hnically di e se pedia ic
popula ion. Pedia ics. (2022) 150:e2021054186. doi: 10.1542/peds.2021-054186
25. Ga cia S, Hop e S, Ama o H, Tanjasi i S. HPV accine delay and e usal among
un accina ed Mexican Ame ican young adul women: a quali a i e in es iga ion o
Mexican-bo n and US-bo n HPV accine decision na a i es. J Beha Med. (2023)
46:88–99. doi: 10.1007/s10865-022-00326-1
26. Pe cac-Lima S, Benne CS, Lui R, Ald ich LS, Oo SA, Regan N, e al. The impac
o a cul u ally ailo ed pa ien na iga o p og am on ce ical cance p e en ion in La ina
women. J Womens Heal h. (2013) 22:426–31. doi: 10.1089/jwh.2012.3900
27. Ins i u e o Medicine (US) Commi ee on he E alua ion o Vaccine Pu chase
Financing in he Uni edS a es. Financing accines in he 21s cen u y: assu ing access and
a ailabili y. 3 d ed. Washing on, DC: Na ional Academies P ess (US) (2003).
54
F on ie s in Public Heal h 01 on ie sin.o g
De e minan s o pneumococcal
accina ion d opou among
child en aged 12–23 mon hs in
E hiopia: a seconda y analysis
om he 2019 mini demog aphic
and heal h su ey
AyenewAsse a
1
*, Teklehaimano Ki os
2, Mula E kihun
2,
Aynewo kAbebaw
3, AyenewBe han
4 and Anda gachewAlmaw
3
1 Uni o Immunology, Depa men o Medical Labo a o y Science, Deb e Tabo Uni e si y, Deb e
Tabo , E hiopia, 2 Uni o Medical Mic obiology, Depa men o Medical Labo a o y Science, Deb e
Tabo Uni e si y, Deb e Tabo , E hiopia, 3 Uni o Pa asi ology, Depa men o Medical Labo a o y
Science, Deb e Tabo Uni e si y, Deb e Tabo , E hiopia, 4 Uni o Hema ology, Depa men o Medical
Labo a o y Science, Deb e Tabo Uni e si y, Deb e Tabo , E hiopia
Backg ound: Vaccina ion is a cos -e ec i e public heal h p og am ha helps
educe signi ican mo bidi y and mo ali y in child en unde he age o i e.
Wo ldwide, he numbe o accine-p e en able causes o child dea h has
signi ican ly dec eased since he Expanded P og am o Immuniza ion (EPI) was
in oduced. Howe e , o a a ie y o easons, 23 million child en did no ha e
adequa e access o accines in 2020. The e o e, his s udy aimed o e alua e he
de e minan s o pneumonia conjuga e accine (PCV) d opou among child en
aged 12–23 mon hs in E hiopia.
Me hods: The s udy analyzed c oss-sec ional da a ob ained om he 2019 mini
E hiopian demog aphic and heal h su ey. Mul ile el bina y logis ic eg ession
analysis was u ilized, and he bes i model was chosen using he Akaike
In o ma ion C i e ia. The s udy comp ised a weigh ed sample o 989 child en
aged 12 o 23 mon hs. The s udy p esen ed he Adjus ed Odds Ra io (AOR) along
wi h a 95% Con idence In e al (CI) o iden i y he signi ican ac o s in luencing
PCV d opou .
Resul s: The PCV d opou a e was epo ed a 20.2% in his s udy. In he
mul ile el analysis, possession o a heal h ca d (AOR = 0.076, 95% CI: 0.019,
0.04), accina ion o PCV 2 (AOR =0.002, 95% CI: 0.023, 0.263), and egion
7 (AOR = 6.98, 95% CI: 10.1, 48.31) we e signi ican ly associa ed wi h child en’s
PCV d opou .
Conclusion: Ha ing a heal h ca d, ha ing ecei ed he PCV 2 accina ions,
and egion we e signi ican p edic o s o PCV d opou . Consequen ly, heal h
educa ion on immuniza ion o all mo he s and egion-speci ic, cus omized
public heal h in e en ions a e needed o educe he accina ion d opou a e.
KEYWORDS
accine, child en, d opou , women, demog aphic and heal h su ey
OPEN ACCESS
EDITED BY
G aça S. Ca alho,
Uni e si y o Minho, Po ugal
REVIEWED BY
Lance Edwa d Kelle ,
Uni e si y o Mississippi Medical Cen e ,
Uni edS a es
Collins Ouma,
Maseno Uni e si y, Kenya
*CORRESPONDENCE
Ayenew Asse a
[email p o ec ed]
RECEIVED 29 Decembe 2023
ACCEPTED 21 June 2024
PUBLISHED 03 July 2024
CITATION
Asse a A, Ki os T, E kihun M, Abebaw A,
Be han A and Almaw A (2024) De e minan s
o pneumococcal accina ion d opou
among child en aged 12–23 mon hs in
E hiopia: a seconda y analysis om he 2019
mini demog aphic and heal h su ey.
F on . Public Heal h 12:1362900.
doi: 10.3389/ pubh.2024.1362900
COPYRIGHT
© 2024 Asse a, Ki os, E kihun, Abebaw,
Be han and Almaw. This is an open-access
a icle dis ibu ed unde he e ms o he
C ea i e Commons A ibu ion License
(CC BY). The use, dis ibu ion o ep oduc ion
in o he o ums is pe mi ed, p o ided he
o iginal au ho (s) and he copy igh owne (s)
a e c edi ed and ha he o iginal publica ion
in his jou nal is ci ed, in acco dance wi h
accep ed academic p ac ice. No use,
dis ibu ion o ep oduc ion is pe mi ed
which does no comply wi h hese e ms.
TYPE O iginal Resea ch
PUBLISHED 03 July 2024
DOI 10.3389/ pubh.2024.1362900
55
Asse a e al. 10.3389/ pubh.2024.1362900
F on ie s in Public Heal h 02 on ie sin.o g
In oduc ion
Pneumonia is an acu e lowe espi a o y ac in ec ion ha damages
he al eola ai space and lung issue. Fo child en unde he age o i e,
pneumonia is he g ea es cause o illness and mo ali y (1). O e 900,000
child en died om pneumonia wo ldwide in 2016, making up a ound
16% o he 5.6 million dea hs o child en unde i e (2). Wi h 50% o he
global dea h a e o child en unde i e caused by pneumonia,
Sub-Saha an A ican na ions ca ied he lion’s sha e o he bu den. In
sub-Saha an A ican na ions, pneumonia is he leading cause o dea h,
accoun ing o abou 172 dea hs pe 1,000 li e bi hs (3, 4). In E hiopia,
pneumonia is he numbe one cause o dea h in he pos na al pe iod as
well as he p ima y cause o mo bidi y and mo ali y in child en unde
he age o i e. Each yea , mo e han 40,000 child en unde he age o i e
die om pneumonia, which accoun s o 20% o all causes o dea h (5, 6).
Pneumonia, which causes signi ican mo bidi y and mo ali y in
child en unde he age o i e, is among he diseases ha can
bep e en ed by accina ion. Vaccina ion is a cos -e ec i e public
heal h p og am ha helps educe hese a es. Wo ldwide, he numbe
o accine-p e en able causes o child dea h has signi ican ly
dec eased since he Expanded P og am o Immuniza ion (EPI) was
in oduced in 1974 wi h he goal o boos ing ou ine immuniza ion
co e age (7). A ound 2 o 3 million child en a yea a e sa ed h ough
accina ion (8). By he end o 2021, he pneumococcal accine had
been launched in 154 membe s a es, and global hi d-dose co e age
was an icipa ed a 51% (9). In No embe 2011, E hiopia added he
10- alen pneumococcal conjuga e accine (PCV 10) o i s childhood
immuniza ion schedule wi h he help o Ga i, he Vaccine Alliance. In
acco dance wi h he na ional accina ion p og am’s h ee-dose
schedule, child en ecei e he sho a 6, 10, and 14 weeks o age (10).
In acco dance wi h Wo ld Heal h O ganiza ion (WHO)
ecommenda ions, child en a e deemed ully immunized when hey
ha e ecei ed he ollowing accina ions by he age o 12 mon hs: BCG
o ube culosis, h ee doses o DPT-Hep B-Hib (diph he ia, pe ussis,
and e anus), pneumonia-conjuga e accine (PCV) and polio, wo doses
o Ro a i us, and a measles sho (11). In 2011, he na ional immuniza ion
p og am added he h ee doses o PCV o he accina ion schedule (12).
Acco ding o E hiopia’s ou ine accina ion schedule, in an s
should begin ecei ing accina ions a bi h and inish hem be o e
u ning 1 yea old. This includes ecei ing a single dose o he Bacillus
Calme e-Gue in (BCG) accine a bi h o as soon as possible, as well
as he i s dose o he o al polio accine (OPV). Th ee doses o he
OPV, Pen a alen , Ro a1, Ro a 2, and pneumonia accines a e gi en a
in e als o 4 weeks du a ion a he 6
h
, 10
h
, and 14
h
weeks, espec i ely,
and inally, he measles accine is gi en a he age o 9 mon hs (13)
(Table1). 90% na ional co e age and 80% dis ic co e age goals we e
se by he Global Vaccine Ac ion Plan and he EPI o he yea 2020 (14).
E en hough immuniza ion a es had inc eased, in 2020, some 23
million child en s ill lacked su icien access o he sho (15–17). By he
end o 2020, 83% ewe child en wo ldwide ha e ecei ed hei childhood
accina ions han he e we e in 2019 (18). A ound 60% o hese child en
esided in low-and middle-income na ions (19). Acco ding o da a om
an E hiopian demog aphic heal h su ey, 39% o child en aged be ween
12 and 23 mon hs in 2016 ecei ed all equi ed accina ions. Because o
his, he coun y’s immuniza ion a es a e o en below he h eshold
needed o c ea e he d immuni y and s op he sp ead o eigh EPI- a ge ed
diseases (20). Nume ous s udies ha e shown ha ac o s such as home
bi h, esidence, mo he ’s knowledge o immuniza ion, home isi s by
heal h wo ke s, dis ance o medical acili ies, misunde s andings abou
he bene i s o immuniza ion, and lack o knowledge abou accine
con aindica ions we e p edic o s o child immuniza ion (21–23).
Full immuniza ion co e age in E hiopia emained ex emely low,
a 33.3%, o all age-app op ia e immuniza ions, including h ee doses
o PCV, despi e he go e nmen ’s e o m ini ia i es. In addi ion, he e
is a no able a ia ion in immuniza ion co e age ac oss a ious pa s
o he coun y (24). Se e al s udies ha e examined he nume ous
ac o s ha may con ibu e o childhood immuniza ion d opou s (25).
To ou knowledge, ew s udies ha e been done on he a es o measles
and polio co e age, bu he e ha e no been any s udies on PCV
co e age o d opou a es using su ey da a om E hiopia. The e o e,
his s udy sough o e alua e he de e minan s o he PCV d opou
a e in E hiopia using he 2019 mini-DHS da a.
Me hods and ma e ials
Da a sou ce and s udy subjec s
The 2019 E hiopian mini demog aphic and heal h su ey (EMDHS)
da a se ed as he da a sou ce o he analysis. I is he second EMDHS
and he i h DHS implemen ed in E hiopia. The su ey was conduc ed
by he E hiopian Public Heal h Ins i u e (EPHI) in collabo a ion wi h
he Cen al S a is ical Agency (CSA), he Fede al Minis y o Heal h
(FMoH), inancial and echnical suppo om de elopmen pa ne s,
and echnical assis ance om he Inne Ci y Fund (ICF). The su ey
was conduc ed om Ma ch 21, 2019 o June 28, 2019, based on a
na ionally ep esen a i e sample ha p o ided es ima es a he na ional
and egional le els and o u ban and u al a eas.
Two adminis a i e ci ies (Addis Ababa and Di e Dawa) and all
nine egions o E hiopia (Tig ay, A a , Amha a, Benishangul-Gumuz,
TABLE1 Rou ine immuniza ion schedule in E hiopia.
Vaccine Disease Age
BCG Tube culosis A bi h
Pen a alen Diph he ia, Pe ussis,
Te anus, H. in luenza
ype b, Hepa i is B
6, 10, 14 weeks
OPV Polio A Bi h, 6, 10, 14 weeks
Measles Measles 9 Mon hs
Pneumonia-conjuga e
Vaccine (PCV)
Pneumonia 6, 10, 14 weeks
Ro a ix ( o a i us
accine)
Ro a i us 6, 10 weeks
Te anus (TT)
immuniza ion o women
in child bea ing age
Te anus 1s con ac p egnancy;
+1 mon h, +6 mon hs;
+1-yea , +1 yea
Abb e ia ions: ANC, An ena al ca e; AIC, Akaike in o ma ion c i e ia; AOR, Adjus ed
odds a io; EA, Enume a ion a ea; EMDHS, E hiopian mini demog aphic and heal h
su ey; EPI, Expanded p og am o immuniza ion; PCV, Pneumonia conjuga e
accine; TT, Te anus oxoid; WHO, Wo ld Heal h O ganiza ion; GHS, Global
Heal h Su ey.
56
F on ie s in Public Heal h 01 on ie sin.o g
Explo ing he ela ionship
be ween accine hesi ancy and
mo he s’ pe spec i es on
COVID-19 accines o child en
ages 5–11 yea s du ing he
omic on p edominan pe iod
2021–2022: a quali a i e s udy
Ti anyA.Su agh *, Da idAdz ago , Ma lynA.Allicock ,
PaulG.Yeh and PaulaCucca o
Depa men o Heal h P omo ion and Beha io al Sciences, School o Public Heal h, The Uni e si y o
Texas Heal h Science Cen e a Hous on (UTHeal h), Hous on, TX, Uni ed S a es
Backg ound: The Uni ed S a es Food and D ug Adminis a ion au ho ized
COVID-19 accines o child en ages 5–11 yea s in Oc obe 2021 du ing he
Omic on p edominan pe iod. Pa en al accine hesi ancy was p e alen du ing
his ime, esul ing in low childhood COVID-19 accine up ake. Mos s udies
explo ing ac o s in luencing pa en al accine hesi ancy ha e ocused on acial
and e hnic mino i ies and lowe socioeconomic popula ions; howe e , he e is
li le knowledge o he d i e d i e s o accine hesi ancy among Whi e pa en s
wi h highe educa ion and socioeconomic s a uses.
Me hods: We conduc ed semi-s uc u ed in e iews wi h a sample o 15
Whi e mo he s o child en ages 5–11 yea s in A lan a, GA, be ween Oc obe –
Decembe 2021. Thema ic analysis was pe o med using NVi o 12.
Resul s: Mo he s we e college-educa ed, homeowne s, and ully accina ed
agains COVID-19. Key indings included dec eased pedia ician’s
ecommenda ions o COVID-19 accines, eliance on in o ma ion om
specialized doc o s and scien is s, dis us in public heal h au ho i ies, high
isk-pe cep ion o COVID-19 accines, and low isk-pe cep ion o COVID-19
disease. Fac o s ela ed o accine accep ance we e al uism and p ac icali y.
Conclusion: This s udy adds o he spa se li e a u e on easons o accine
hesi ancy among Whi e mo he s o child en ages 5–11 yea s wi h highe
educa ional and socioeconomic s a us. Imp o ing accine up ake among
his g oup is c i ical o p o ec ing he heal h o hei child en and o he
ulne able popula ions. Tailo ed accine messaging and in e en ion a e
wa an ed o add ess hei unique a i udes, belie s, and beha io s. An enhanced
unde s anding o he ac o s in luencing subpopula ions o pa en s can help
accine policymake s and heal hca e p o ide s imp o e e o s o educe
accine hesi ancy, pa icula ly o new accines.
KEYWORDS
COVID-19, childhood accina ion, accine hesi ancy, accine e usal, quali a i e
OPEN ACCESS
EDITED BY
Ca los Albe o De Oli ei a Magalhães Júnio ,
S a e Uni e si y o Ma ingá, B azil
REVIEWED BY
Ri a Gill Singh,
Hong Kong Bap is Uni e si y, Hong Kong
SAR, China
Ronaldo Ad iano Ribei o Da Sil a,
Uni e sidade Fede al da In eg ação
La ino-Ame icana, B azil
*CORRESPONDENCE
Ti any A. Su agh
Ti any[email p o ec ed]
RECEIVED 14 Decembe 2023
ACCEPTED 11 June 2024
PUBLISHED 08 July 2024
CITATION
Su agh TA, Adz ago D, Allicock MA,
Yeh PG and Cucca o P (2024) Explo ing he
ela ionship be ween accine hesi ancy and
mo he s’ pe spec i es on COVID-19 accines
o child en ages 5–11 yea s du ing he
omic on p edominan pe iod 2021–2022: a
quali a i e s udy.
F on . Public Heal h 12:1355452.
doi: 10.3389/ pubh.2024.1355452
COPYRIGHT
© 2024 Su agh, Adz ago, Allicock, Yeh and
Cucca o. This is an open-access a icle
dis ibu ed unde he e ms o he C ea i e
Commons A ibu ion License (CC BY). The
use, dis ibu ion o ep oduc ion in o he
o ums is pe mi ed, p o ided he o iginal
au ho (s) and he copy igh owne (s) a e
c edi ed and ha he o iginal publica ion in
his jou nal is ci ed, in acco dance wi h
accep ed academic p ac ice. No use,
dis ibu ion o ep oduc ion is pe mi ed
which does no comply wi h hese e ms.
TYPE O iginal Resea ch
PUBLISHED 08 July 2024
DOI 10.3389/ pubh.2024.1355452
63
Su agh e al. 10.3389/ pubh.2024.1355452
F on ie s in Public Heal h 02 on ie sin.o g
1 In oduc ion
The co ona i us disease (COVID-19) pandemic has highligh ed
he implica ions o accine hesi ancy on low accine up ake and
accep ance (1). I has demons a ed accine hesi ancy’s h ea o
indi idual and popula ion-le el p o ec ion agains highly in ec ious
diseases (1, 2). Vaccine hesi ancy – he delay o e usal o a accine
despi e i s a ailabili y – is associa ed wi h low COVID-19 accine
up ake among child en (3–5). COVID-19 has esul ed in nega i e
heal h ou comes in child en, including mul isys em in lamma o y
synd ome (MIS-C). This has esul ed in hospi aliza ions and dea hs in
child en ages 5–11 yea s (6, 7). Nea ly 15.6 million child en in he
Uni edS a es (U.S.) ha e es ed posi i e o COVID-19 (7), wi h he
highes numbe o cases occu ing du ing he Omic on p edominan
pe iod 2021–2022. The FDA au ho ized he P ize -BioNTech
COVID-19 accine o eme gency use in child en ages 5–11 yea s on
Oc obe 29, 2021 (8). COVID-19 accina ion is he mos e ec i e way
o educe child en’s COVID-19 mo bidi y and mo ali y, ye
accina ion co e age emains subop imal, wi h Whi e child en ha ing
some o he lowes accina ion a es (45%) compa ed o Asian and
Hispanic Child en (75 and 49%, espec i ely) (9). Geog aphic
di e ences in accina ion co e age also exis , wi h eigh o he 10
s a es ha ing he lowes accina ion co e age in he Sou h (10).
Vaccine hesi ancy may explain he accina ion co e age dispa i ies
among child en ages 5–11 yea s. Vaccine hesi ancy s ongly in luences
pa en s’ decisions o accina e hei child en and is a complex no ion
a ying ac oss accine ypes, imes, and se ings (3). The Wo ld Heal h
O ganiza ion’s (WHO) Inc easing Vaccina ion Model (IVM) p oposes
ha accine up ake is based on people’s hough s and eelings, such as
pe cei ed isks and bene i s, and social p ocesses, like social no ms
and in o ma ion (11). In addi ion o hese ac o s, p ac ical issues such
as accine cos and a ailabili y esul in accine accep ance, delay, o
e usal (11). Vaccine hesi ancy is in luenced by mul iple in e ela ed
ac o s, and some indi iduals may accep some accines and e use o
delay o he s (12).
Reasons o pa en al COVID-19 accine hesi ancy included he
accine’s no el y and lack o con idence in i s sa e y and e icacy (13–
18). Fo example, pa en s desc ibed ha he accines we e de eloped
oo quickly and we e no well s udied leading o conce ns abou
unknown accine isks and po en ial side e ec s, such as myoca di is
and e ili y issues (14, 19, 20). The changing accine
ecommenda ions, including he need o boos e s and accine dosage
in child en, also c ea ed con usion and doub among pa en s ega ding
he necessi y o childhood accina ions (14–17, 21, 22). S udies ound
ha accine-hesi an pa en s ended o ha e less knowledge o
accines, leading o less con idence in he accine’s e icacy (19).
Belie s ha COVID-19 was mo e se e e in child en wi h p e-exis ing
condi ions and adul s led o accine hesi ancy among pa en s who el
hei child en we e heal hy and did no eel compelled o p o ec he
communi y a la ge (14–16). Dis us o go e nmen and public heal h
o icials also con ibu ed o conspi acy heo ies and misin o ma ion
abou he COVID-19 accine (13, 14, 17–20). This misin o ma ion
sp ead quickly h ough social media, whe e some pa en s seek accine
in o ma ion (18–20). These belie s we e pe sis en e en among pa en s
ully accina ed agains COVID-19 (13, 23).
Vaccine hesi ancy is also la gely in luenced by demog aphics such
as ace, income, and educa ional le el (24, 25). A common belie is
ha accine-hesi an indi iduals a e o lowe income and educa ional
s a us and occu mos ly among acial and e hnic mino i ies (13, 25,
26). Howe e , accine hesi ancy is p e alen among Whi e indi iduals
and hose wi h highe educa ional le els and socioeconomic s a us
(24, 27). This may bedue o he en i onmen s in which hey li e and
wo k, which migh limi hei exposu e o la ge g oups o people (e.g.,
c owded schools and houses) and in luence hei pe cep ions o
disease se e i y. A Kaise Family Founda ion poll ound ha pa en s
who a e Black o Hispanic a e less likely o eel hei child is “ e y sa e”
om COVID-19 a school han Whi e pa en s (33% s. 52%) (28).
Many s udies examining pa en al pe cep ions o childhood
COVID-19 accines ha e been quan i a i e (13, 16, 21–23), wi h ew
quali a i e s udies (14, 15, 29). Quali a i e esea ch allows he
ga he ing o ich da a and explo a ion o hough s and eelings ha
enable esea che s o gain insigh in o decision-making p ocesses and
help explain human beha io , including a mo he ’s decision o
accina e hei child agains COVID-19 (30). To ou knowledge, his
was one o he ew quali a i e s udies o explo e ma e nal pe cep ions
o COVID-19 accines o child en ages 5–11 immedia ely a e he
FDA in oduced he accine. Las ly, mos o he li e a u e has ocused
on d i e s o accine hesi ancy among acial and e hnic mino i ies
and hose wi h lowe socioeconomic s a us (31–33). Limi ed
in o ma ion exis s on ac o s in luencing COVID-19 hesi ancy among
Whi e, highe -income, and educa ed pa en s. I is c i ical o inc ease
accine up ake among his subpopula ion o p o ec hei child en and
o he ulne able g oups and inc ease accine up ake.
The objec i e o he s udy was o unde s and he belie s, a i udes,
and beha io s o Whi e mo he s o high socioeconomic s a us and
educa ion le els ega ding COVID-19 accina ion among child en
ages 5–11 yea s. Findings can ha e clinical and policy implica ions,
such as be e s a egies o a ge di e en subpopula ions o pa en s
wi h unique accine hesi ancy conce ns and needs.
2 Me hods
2.1 Pa icipan s
We conduc ed semi-s uc u ed in e iews wi h 15 mo he s om
Oc obe o Decembe 2021. Weused pu posi e sampling o ec ui
mo he s. The sample was ec ui ed p ima ily om one childca e
se ice/company ha connec s amilies wi h in-home ca e in A lan a,
GA, and he es o he sample was ob ained h ough snowball
sampling. The lead au ho emailed he childca e se ice desc ibing he
s udy and asked i he in o ma ion could bepassed o mo he s. A e
each in e iew was comple ed, he lead au ho asked he pa icipan
o sha e in o ma ion abou he s udy wi h o he mo he s who migh
bein e es ed. Mo he s we e eligible o pa icipa e i hey had a child
ages 5–11 yea s, li ed in A lan a, GA, and spoke English.
2.2 Da a collec ion
We used semi-s uc u ed in e iews o c ea e dialog while allowing
o eme gen ideas (34, 35). Wede eloped a semi-s uc u ed in e iew
guide based on a li e a u e e iew and consul a ion wi h expe s in
quali a i e esea ch and accine hesi ancy, including acul y a he
Uni e si y o Texas Heal h Science Cen e a Hous on (UTHeal h
Hous on). In e iew ques ions we e no ied o a pa icula heo y o
64
Su agh e al. 10.3389/ pubh.2024.1355452
F on ie s in Public Heal h 03 on ie sin.o g
amewo k o allow esea che s o ga he ich, complex da a wi hou
being cons ained by heo e ical cons uc s. Mo he s we e asked b oad,
open-ended ques ions abou hei pe cep ions o ou ine and COVID-19
childhood accines. Ques ions cen e ed a ound hei iews o
COVID-19 accines and how his compa ed o ou ine childhood
accines, us ed sou ces o COVID-19 accine in o ma ion, pe cep ions
o COVID-19 disease, and ac o s ha would in luence hei decision o
accina e hei child agains COVID-19. Ve bal consen was ecei ed
be o e he in e iews. In e iews las ed 45–60 min and we e audio and
ideo eco ded using Zoom (Zoom Video Communica ions Inc., 2016).
In e iews we e p o essionally ansc ibed e ba im, and ansc ip s
we e independen ly coded by a p ima y (TS) and seconda y (DA)
e iewe . A hi d e iewe esol ed disag eemen s o codes (PC).
2.3 Da a analysis
Thema ic analysis was pe o med and included deduc i e and
induc i e app oaches using NVi o 12 so wa e ( eleased in Ma ch
2020) (36). U ilizing B aun and Cla ke’s hema ic con en analy ic
app oach, he esea che s (TS & PC) i s conduc ed mul iple
ansc ip eadings ha we e discussed among he esea ch eam o
de elop a codebook ha aligned wi h he esea ch ques ion and s udy
objec i e (37, 38). Eme gen hemes we e discussed among he
esea che s and used in e ising he codebook. Analysis con inued
wi h he e inemen o codes un il sa u a ion was me and no new
codes o hemes eme ged (39). All s udy p ocedu es we e app o ed by
he Commi ee o he P o ec ion o Human Subjec s ( he ins i u ional
e iew boa d) a UTHeal h Hous on (HSC-SPH-11-0577).
3 Resul s
3.1 Sample
In o al, 15 mo he s wi h child en ages 5–11 yea s comple ed
indi idual in e iews. Pa icipan s we e Whi e, college-educa ed
homeowne s and he majo i y epo ed ecei ing wo doses o
COVID-19 accines o hemsel es. Pa icipan s’ ages anged om 36
o 47 yea s (Table 1). Pseudonyms we e used o desc ibe he
pa icipan s o p o ec he iden i y o he pa icipan s and because he
sample was demog aphically simila (40). The majo i y o mo he s
we e hesi an abou COVID-19 accines, and hei hesi ancy was
d i en by he un amilia i y and no el y o he accine, balancing he
isks and bene i s o he accine, dis us in go e nmen , science, and
public heal h au ho i ies, dec eased us in pedia icians and inc eased
us in medical specialis s. Mo he s who we e accep ing o COVID-19
accines had a g ea e ea o ad e se e ec s o COVID-19 disease han
he accine and wan ed o e u n o no malcy wi h child en in school
and p o ec he g ea e communi y. The ollowing hemes eme ged in
ela ion o COVID-19 accine hesi ancy and accine accep ance:
3.2 Vaccine hesi ancy is in luenced by he
un amilia i y and no el y o he accine
Mo he s desc ibed hei unwillingness o accina e hei child en
based on hei le el o amilia i y and no el y su ounding COVID-19
accines. Rou ine accines o known illnesses such as in luenza we e
iewed di e en ly om eme gen diseases like COVID-19. Fo
ou ine childhood accines like he Ro a i us accine, mo he s
desc ibed con idence in he accines’ sa e y and e icacy due o he
leng h o ime he accines had been a ound and ha ing been
accina ed hemsel es as a child. This amilia i y esul ed in mo he s’
con idence and accep ance o ou ine accines as ecommended by
hei pedia icians. Con e sely, unce ain y and ea led o he
nonaccep ance o childhood COVID-19 accines. Mo he s exp essed
he accine’s no el y, as de elopmen , and unknown long- e m side
e ec s as easons o low con idence in he accine. Pa adoxically,
mo he s who we e accina ed agains COVID-19 unwilling o
accina e hei child en, and hesi an o ollow hei pedia ician’s
ecommenda ions as hey no mally would be o e he COVID-19
accine. Lau en exp essed he iews on ou ine and
COVID-19 accines,
… Ip e y much jus ollowed he s anda d doc o ’s guidelines. So,
whene e …we had a doc o ’s appoin men when hey we e li le
kids…. Ialways consen ed o hem o ge he accines. Ine e
delayed… he accines ha weha e done in he pas ha e been
a ound o such a long ime, and so he e’s a lo o , youknow,
e idence ha hey a e no ha m ul. And wi h… hese [COVID-19]
accines, hey ha e come ou so quickly, go en h ough he
app o al p ocess so quickly (Lau en, mo he o 2 child en).
The as app o al and quick manu ac u ing o COVID-19 accines
made mo he s wonde i he accine isks ou weighed he bene i s.
3.3 Balancing he isks and bene i s o
childhood COVID-19 accina ion
Some easons unde lying mo he s’ hesi ancy owa ds COVID-19
accines we e due o unknown and po en ial long- e m side e ec s,
pa icula ly hei no el y and he sho manu ac u ing imes o hese
accines. Ma ia exp essed conce ns abou possible side e ec s,
I hink i ’s p obably e ec i e and sa e. Because I eel like people,
millions o people, hope ully, would no be aking i i i wasn’ .
Iguess because i ’s so new, wedo no know wha any o he
TABLE1 Demog aphic cha ac e is ics o mo he s o child en ages
5–11 yea s (N = 15).*
Demog aphics N (%) %
Age (yea s)
29–39 10 67
40–49 5 33
Educa ion
Bachelo ’s deg ee 5 33
G adua e deg ee 10 67
Numbe o child en
1–2 11 73
3–4 4 27
*Mo he s we e all Whi e, owned hei homes and we e accina ed agains COVID-19.
65
Su agh e al. 10.3389/ pubh.2024.1355452
F on ie s in Public Heal h 04 on ie sin.o g
long- e m side e ec s a e. Like, is my son going o ha e e ili y
issues la e ? Is i going o a ec his spe m? (Ma ia, mo he o
2 child en).
These conce ns ou weighed any pe cei ed bene i o accina ion.
The belie ha accina ing child en would p o ec hem and he
communi y did no mo i a e mo he s owa d accina ion. Rachel
exp essed he ambi alence abou COVID-19 accines,
I hink i is one o he ha des decisions ha I’ e e e had o make
o my kids… wea e no se on which way we’ll go igh now…
you jus do no wan o do any hing o ha m you kids…. And
his, I’m no con inced wea e doing i o he kids ye and ha
makes me eally ne ous, and Ido no wan o make a bad decision
o hem…because i could a ec hem o he es o hei li e.
And he e’s jus so much unknown (Rachel, mo he o 2 child en).
A sen imen exp essed by mo he s was ha hei child en we e
no a isk o se e e complica ions om COVID-19 because hey
we e heal hy and unexposed o la ge g oups. Some mo he s desc ibed
ha ing pods o 4–5 child en ha s udied and played oge he when
schools we e closed and no ha ing o bea ound many people. Oli ia
sha ed he easons o wai ing o accina e,
My child en, luckily, do no ha e any p oblems o he han being
p eemies. They a e no obese. The e a e no obacco use s in ou
li e. We’ e e y hank ul no o ha e any o hose so s o isk
ac o s. Wealso li e in A lan a, whe e wedo no ide public
anspo a ion on a egula basis…we a e no exposed o big
c owds, ha kind o hing. I migh bedi e en i Iwas aking a
subway in NewYo k Ci y e e y day and come in con ac wi h a lo
o people, bu , my plan is o wai a leas wo yea s… (Oli ia,
mo he o 2 child en).
3.4 Vaccine hesi ancy in luenced by
dis us science
Vaccine hesi ancy was in luenced by dis us in go e nmen and
public heal h o icials and inc eased us in medical and in ec ious
disease specialis s.
Mo he s who we e hesi an abou childhood COVID-19 accines
desc ibed hei lack o con idence and us in he scien i ic
in o ma ion dissemina ed o he public by he go e nmen , accine
manu ac u e s, and public heal h o icials. They we e skep ical abou
he accine’s sa e y and e icacy due o he pe cei ed lack o igo in
he scien i ic s udies. Mo he s did no hink he e was enough
e idence o jus i y childhood COVID-19 accina ion and we e no
con inced accina ion was he decision o hei child en. Thei abili y
o in e p e scien i ic in o ma ion independen ly in luenced hei us
and con idence in science.
Sa ah exp essed he doub s,
… his expe ience has d ama ically changed my pe spec i e on ou
medical ins i u ions and he amoun o us Iha e in hem in a
majo way…The sample size wi h kids o he P ize es ing was…
oughly, like, a li le unde 2,200. Tha , o me, is no a la ge enough
sample wi h a la ge enough ime pe iod o me o sign my kid
up… (Sa ah, mo he o 3 child en).
The changing and con lic ing messaging by he public heal h
au ho i ies du ing he COVID-19 pandemic con ibu ed o mo he s’
unce ain y abou he accine. Messages, like he leng h o ime
child en needed o wai o be accina ed a e ha ing COVID-19, he
spacing o COVID-19 and o he childhood accines, and ace mask
guidelines led o mo he s’ doub ing he accu acy o in o ma ion
channeled h ough adi ional sou ces, including hei pedia icians.
Despi e ha ing es ablished ela ionships wi h hei pedia icians,
mo he s now el hem o beless us wo hy and knowledgeable o
he e icacy and sa e y o childhood COVID-19 accines. Ashley s a ed,
“…ou doc o has been sending ou emails e e y week abou how
sa e he accine is. And Imean ha ’s g ea , bu . And like how sa e
masking is o kids, bu Ijus do no eally, um, i ’s jus no o my
as e. So, p obably no he doc o … he e a e some news ou le s
ha I ind o bec edible…” (Ashley, mo he o 4 child en).
Al e na i ely, mo he s elied on in o ma ion om special y
doc o s like ca diologis s and in ec ious disease specialis s. Unlike
pedia icians, whom hey el would ecommend he accine
ega dless o po en ial sa e y conce ns, mo he s el specialis s
p o ided mo e hones and independen e iews o childhood
COVID-19 accines. Fo example, mo he s el mo e com o able
speaking o ca diologis s ega ding he po en ial isk o hea
in lamma ion (e.g., myoca di is and pe ica di is) ollowing COVID-19
accina ion. This eliance on specialis s was acili a ed by he
p oximi y and access o hese p o essionals, who we e hei neighbo s,
iends, and amily membe s. Ma ia exp essed he easons o
inc eased eliance on specialis doc o s, “…I lo e hei pedia ician,
and weha e a eally good ela ionship wi h him…I eel like he
epidemiologis is close o his speci ic ocus…I know my doc o is
no in he lab es ing accines…he’s no on he on lines.” (Ma ia,
mo he o 2 child en). This shi ing us in science in luenced
mo he s’ pe cep ion o he se e i y o COVID-19in child en and he
isks associa ed wi h he COVID-19 accine. Mo he s did no men ion
eliance on specialis s o ou ine accines, and i appea s his shi in
pe cep ion was ela ed o he no el y and un amilia i y o he
COVID-19 accine as well as based on hei us ed sou ces o
accine in o ma ion.
3.5 Vaccine hesi ancy in luenced by us in
sou ce o COVID-19 accina ion
in o ma ion
A key d i e o accine hesi ancy among mo he s was hei le el
o us in he sou ces o in o ma ion p omo ing childhood COVID-19
accina ion. I mo he s did no us he in o ma ion o agenda o
ins i u ions and au ho i ies, hey we e less con iden ha he accine
was he bes decision o hei child en. Sou ces deemed us wo hy
included scien i ic websi es and o ganiza ions (e.g., he Mayo Clinic),
news, podcas s, ca diologis s, epidemiologis s, amily, and iends.
While mo he s men ioned iewing in o ma ion on social media
pla o ms like Facebook, hey did no conside hese pla o ms
us wo hy o hei p ima y sou ce o accine in o ma ion. They
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F on ie s in Public Heal h 05 on ie sin.o g
desc ibed he ex en o which hey would ac i ely seek ou in o ma ion
and make hei conclusions abou he accine (e.g., sea ching o
ad e se e en s ollowing COVID-19 accina ion on publicly a ailable
go e nmen da abases) ins ead o passi ely accep ing in o ma ion.
Sa ah desc ibed how she sea ched o c edible in o ma ion,
… I ead he NewYo k Times e e y mo ning, and I ead he
AJC [The A lan a Jou nal-Cons i u ion] e e y mo ning…I
also, youknow, Google hings. And when IGoogle hings,
I y o click websi es ha I ecognize and ha a e hings like
John Hopkins, Mayo Clinic… hings ha seem like hey would
no ge away wi h misin o ma ion… (Sa ah, mo he o
2 child en).
Mo he s we e also keenly awa e ha poli ics hea ily in luenced
he dissemina ion o COVID-19 accine in o ma ion. They desc ibed
he di e ing opinions ega ding childhood COVID-19 accines’ sa e y
and necessi y based on conse a i e e sus libe al sou ces o
in o ma ion. The poli iciza ion o he COVID-19 pandemic led
mo he s o ques ion he ue mo i a ions behind campaigns
p omo ing childhood COVID-19 accina ions and whe he accines
we e being used o poli ical gain a he han o p o ec hei child en’s
heal h. This pe cep ion con ibu ed o mo he s’ eluc ance o accina e
as hey e used o pu hei child en a isk o unknown side e ec s
due o poli ical p essu e, c ea ing doub abou he e aci y o he
scien i ic in o ma ion being used o p omo e he accine o child en.
Rachel exp essed he conce ns,
…I do no us he poli ics, and some o [ he] encou agemen o
gi e i o hem [child en] is o p o ec adul s who e used o ge i
hemsel es. And ha ’s no ai . Ido no wan o do some hing o
my kids ha he s udies ha e no been ully done on o p o ec
adul s, who a e old enough o decide o hemsel es and ha e he
ee choice o do i o no , and i ’s hei aul i hey do no .
Icanno help ha in my opinion. And I’m no gonna punish my
kids because hey [adul s] do no [ge accina ed] (Rachel, mo he
o 2 child en).
3.6 Vaccine accep ance in luenced by ea
o COVID-19 disease and wan ing o e u n
o no malcy
The belie ha COVID-19 accines could p o ec child en and he
communi y esona ed wi h some mo he s and a ec ed hei decision
o accina e hei child en. Mo he s who al eady accina ed hei
child en agains COVID-19, o in ended o, belie ed he bene i s o
accina ion ou weighed he po en ial long- e m isks o COVID-19
disease. Ka he ine exp essed he conce ns,
…I’m eally ne ous abou he long- e m e ec s o my son ge ing
COVID because…Like, wha i i causes some lung issues and he’s
no able o play socce like hedoes…we kind o know igh now
om he ials ha he e’s no going o be hese eally long long-
e m e ec s om he COVID accine, whe eas Ido no eel like
weknow ha o ac ual COVID-19 in ec ion…I do no hink he
COVID accine is going o make my son su e , bu Ido eel like
COVID, po en ially, in he long un, could make him su e …”
(Ka he ine, mo he o 1 child).
A mino i y o mo he s accep ed he accine o easons like ewe
missed school days and he abili y o a el. They desc ibed olde
amily membe s as mo e a isk o se e e complica ions o COVID-
19, and accina ing hei child en was a way o allow hem o spend
ime wi h o he s sa ely. Fo hese women, al uism and p ac ical
easons ou weighed he pe cei ed isks associa ed wi h he accine.
Allison exp essed he conside a ions,
… besides he heal h, he e’s also he logis ics. Like I eel like
Iwo k in a hospi al, and hey a e a isk, and so Iwan ed hem
p o ec ed. The e’s also, a he schools, Iknow ha he e will
bedi e en equi emen s o qua an ining i he e’s exposu es,
and i hey ha e accines, hen hey will no ha e o qua an ine,
so he e will no bemissed school…and all o ha was eally
impo an o me. I do no wan my kids lea ning i ually
anymo e, e e , i possible… (Allison, mo he o 2 child en).
Rega ding he logis ics o a eling, Lau en s a ed,
…we ha e some in e na ional a el coming up, so…we said,
“Okay. Well, maybe we should go ahead and ge he kids
accina ed…And i ’s hones ly less o he ac ha youknow,
we hink i ’ll p e en hem om con ac ing [COVID-19
in ec ion] o hei symp oms, bu mo e om he ac o , youknow,
wedo no wan any dis up ions o he a el, o bequi e hones …
(Lau en, mo he o 2 child en).
4 Discussion
Ou s udy iden i ied key ac o s ela ed o accine hesi ancy and
accep ance o childhood COVID-19 accines among Whi e, mo he s o
child en ages 5–11 yea s om highe educa ional and socioeconomic
backg ounds. Mo he s who we e accine-hesi an exp essed
un amilia i y and ea o unknown ad e se e ec s o COVID-19
accines, dec eased us in pedia icians’ ecommenda ions, and
dis us in science and public heal h au ho i ies. Mo he s who we e
accine-accep an exp essed sen imen s including us in he science
and public heal h au ho i ies, ea o COVID-19, and aspec s o al uism
such as wan ing o p o ec hei child en, amily, and communi y.
Reasons o p ac icali y and wan ing o e u n o no malcy we e also
no ed o accep ing childhood COVID-19 accines.
Ou indings ein o ce he no ion ha accine hesi ancy is a
complex phenomenon and accine decision-making is in luenced by
many con ex ual ac o s (3, 11, 12). Indi iduals canno beg ouped
exclusi ely as “hesi an ” o “accep an .” Mo he s in ou s udy we e
hesi an o accina e hei child en wi h COVID-19 accines ye
accep ed ou ine childhood accines like polio and in luenza. Mo he s’
amilia i y wi h ou ine accines, such as ha ing aken hese accines as
child en and unde s anding hei sa e y p o iles, in luenced hei
decisions o accina e hei child en. This inding aligns wi h esea ch
ha ound pa en s accep ing some bu no all accines and mo he s
accina ed agains COVID-19, ye s ill hesi an o hei child en
(12, 13, 23). The no el y o COVID-19 accines ou ine accines made
67
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F on ie s in Public Heal h 06 on ie sin.o g
mo he s eel less con iden in he accines’ sa e y and e icacy (13–18).
Simila o o he s udies, mos o he mo he s in ou s udy we e ully
accina ed agains COVID-19 bu we e s ill conce ned abou he
accine’s sa e y in hei child en, o example, ci ing long- e m e ili y
issues (13, 14).
Ou indings align wi h o he accine ends ha ha e shown
demog aphic ac o s, including Whi e, a luen , educa ed pa en s who
a e leas likely o accina e hei child agains he human
papilloma i us (HPV) and a e a majo g oup wi hin he an i- accine
mo emen (41–43). Despi e his subpopula ion ha ing ewe po en ial
ba ie s o accina ion (e.g., inancial ins abili y and lowe educa ion),
hei decision-making is in luenced by hei esea ch, weighing he
bene i s and isks o accina ion, and pe sonal belie s alues, and
a i udes (44–46). In ou s udy, mo he s accessed, e iewed, and
in e p e ed publicly a ailable go e nmen da ase s on ad e se e en s
ollowing childhood COVID-19 accina ion o help hem unde s and
he accine’s sa e y and side e ec s. Fo example, mo he s who
belie ed he sample sizes o he clinical ials we e small may eel mo e
con iden in hei decision o accina e hei child i hey ecei ed
de ailed in o ma ion on how o in e p e sample size calcula ions and
accine e icacy (45). This misunde s anding o COVID-19 scien i ic
in o ma ion being dissemina ed by he go e nmen and public heal h
o icials led o dis us in hese en i ies and is a common heme in he
li e a u e. I is essen ial o policymake s o inc ease e o s o de elop
ailo ed ma e ials ha o e mo e anspa en accine sa e y
in o ma ion o a subg oup o pa en s who a e well-in o med and
access esou ces ha mos pa en s migh no know exis (e.g., publicly
a ailable go e nmen su eillance da abases). Fo example, accine
messaging can include mo e echnical in o ma ion, such as how o
in e p e scien i ic da a om clinical ials and go e nmen accine
su eillance sys ems (44–46). These e o s can inc ease accine
con idence and us among pa en s.
S udies ha e ound pedia ic heal hca e p o ide s o be he mos
us ed sou ces o accine in o ma ion and acili a o s o childhood
accine up ake (14, 21, 22, 44). We ound con as ing e idence as
mo he s in ou s udy exp essed dec eased us in hei pedia icians
and inc eased eliance on medical specialis s like ca diologis s and
epidemiologis s o COVID-19 accine in o ma ion. Du ing he
H1N1 pandemic, indi iduals also los us in he go e nmen and
heal h au ho i ies, dec easing hei willingness o ge accina ed (47).
Pa en al accine hesi ancy is in luenced by many ac o s, such as
accine ype and how i was in oduced (e.g., du ing a pandemic o
mass accina ion campaign) (44–46). I is essen ial o s eng hen long-
s anding ela ionships be ween pedia icians and pa en s, especially
du ing a pandemic, when pa en s may bemo e conce ned and less
us ing o scien i ic in o ma ion. Policymake s can conside how o
de elop ools o encou age collabo a i e p o ide -pa en
communica ion. C ea ing an en i onmen whe e pa en s eel
con iden in he in o ma ion ecei ed as opposed o eeling p essu ed
o accina e hei child agains hei will o despi e hei conce ns can
bebene icial among subg oups o pa en s like hose in ou s udy
(45, 48).
The poli iciza ion o COVID-19 accines in luenced mo he s’
hesi ancy owa ds accina ing hei child en agains COVID-19.
Mo he s exp essed dis us in he ue mo i a ions o public heal h
au ho i ies ecommending childhood COVID-19 accina ion. The
belie ha poli icians misused COVID-19 accine in o ma ion o
hei poli ical gains aligned wi h esea ch ha sugges ed public
con idence in COVID-19 accines was a ec ed by how he
go e nmen handled he COVID-19 pandemic (49). A poll by he
Kaise Family Founda ion ound poli ical a ilia ion o bea s onge
p edic o o whe he someone is accina ed han demog aphic ac o s,
such as educa ion, ace, and age (50). Conside ing how social,
con ex ual and poli ical ac o s may in luence accine a i udes and
belie s, highligh s he impo ance o public heal h o icials le e aging
mul iple communica ion channels o add ess pa en al conce ns (51).
Mo he s in ou s udy men ioned podcas s and medical
websi es as us ed sou ces o in o ma ion. Podcas s we e p e e ed
because hey o e ed di e ing iews o childhood accina ion, and
mo he s app ecia ed he neu ali y o discussions. This neu ali y
coun e ed he pa isan bias ypically ound in adi ionally
conse a i e and libe al news. In e es ingly, social media was no
ega ded as a sou ce o accine in o ma ion bu a he jus a place
o socialize, con as ing he moun ing e idence ha
misin o ma ion on social media in luences accine decision-
making (18, 20, 52). Fo mo he s simila o ou sample, i may
bemo e e ec i e o dissemina e public heal h messaging ega ding
childhood COVID-19 accina ion h ough ou le s no ela ed o
social media.
Ou indings also highligh ed he nuances in pa en al and child
COVID-19 accina ion s a us. While o he s udies ound pa en s
accina ed o in ended o accina e agains COVID-19 also
in ended o accina e hei child en (13, 16), ou s udy yielded
di e en indings. The majo i y o mo he s in ou s udy we e all
accina ed agains COVID-19 and accep ed he isks o accina ion
o hemsel es. Ye some we e s ill hesi an and unwilling o pu
hei child en a simila isk. Child en ages 5–11 yea s a e di e en
han olde age g oups, such as adolescen s who may ha e some
au onomy a ound accine decision-making (15). The e o e,
mo he s o young child en may eel an e en g ea e esponsibili y
o hei child’s heal h.
Simila o o he s udies, pa en al mo i a ions o accina ing hei
child agains COVID-19 included a desi e o p o ec he b oade
communi y, e u n o no malcy, and mi iga e he nega i e social and
emo ional consequences o COVID-19, such as educa ional losses due
o missed school (14, 16). Mo he s exp essed ge ing hei child en
accina ed so hey could a el in e na ionally, and i would appea
ha he amilial and logis ical bene i s o accina ion would ou weigh
any pe cei ed isks associa ed wi h he accine. Mo he s in ou sample
we e highly a luen and may ha e di e en mo i a ions o wan ing
hei child accina ed han less a luen mo he s Also, policymake s
may wan o emphasize he impo ance o school-based in e en ions
and immuniza ion policies ha can encou age accine up ake in
child en (53).
Vaccine hesi ancy can be concep ualized as linea s ages o
hesi ancy and non-hesi ancy based on he Inc easing Vaccina ion
Model and he P ecau ion Adop ion P ocess Model (11, 54, 55). Some
mo he s in ou s udy would all wi hin he s ages o undecided (i.e.,
conside ed bu no ye decided) and e use (i.e., conside ed and
decided o e use). A no able di e ence wi h ou indings is ha he
p ocess may no belinea . Fo example, some mo he s immedia ely
e used childhood COVID-19 accines wi hou i s being undecided.
This beha io highligh s he complexi ies o unde s anding accine
hesi ancy. The e is a public heal h need o shi mo he s om
undecided o decided, and unde s anding he pe spec i es o mo he s
who may ha e ewe inancial ba ie s and access o mo e esou ces,
68
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F on ie s in Public Heal h 07 on ie sin.o g
such as hose who a e highly educa ed, can help in ailo ing policy-
d i en in e en ions. Fo mo he s who accep ed COVID-19 accines,
acco ding o he model abo e, some would s ill be classi ied as
“decided bu no ye highly educa ed” due o delays in ge ing hei
child accina ed. These mo he s desc ibed echnical ba ie s like
being pu on a wai lis o see hei doc o . Despi e he a ie y o places
whe e COVID-19 accina ion is a ailable, i is possible ha mo he s
eel mo e com o able accina ing hei child en in a pedia ician’s
o ice o a school se ing. This p e e ence may in o m policy decisions
ela ed o accine dis ibu ion and unde s anding how hese ba ie s
may be educed o acili a e as e accina ion o willing pa en s.
4.1 S eng hs and limi a ions
Ou quali a i e app oach allowed o a deepe explo a ion o
Whi e mo he s o highe educa ional and socioeconomic s a uses’
pe spec i es, p oducing ich da a ha o e mo e con ex han
quan i a i e su ey da a. While s udies ha e highligh ed in luence s
o accine hesi ancy among mino i y popula ions, e y ew ha e
ocused on highe socioeconomic popula ions. We ound mo he s
wi h highe educa ional and inancial s a us hesi an o accina e hei
child en ages 5–11 yea s agains COVID-19. This inding sugges s ha
pa en s o a ious backg ounds ha e di e en belie s and alues, and
u u e public heal h e o s should conside his when p omo ing
accine up ake. These di e ences a e especially c i ical du ing he
ea ly mon hs o a accine’s ollou du ing a pandemic when many li es
a e a isk (47, 56, 57). Ou quali a i e s udy is one o he ew s udies
ha occu ed when he FDA au ho ized he P ize -BioNTech
COVID-19 accine o eme gency use in child en ages 5–11 yea s and
ep esen ed ea ly iews and pe cep ions. Addi ionally, COVID-19
accine up ake in child en ages 5–11 yea s emains subop imal, wi h
Whi e child en ha ing he hi d lowes accina ion co e age. These
indings may help explain why Whi e pa en s o highe educa ional
and socioeconomic s a us migh s ill behesi an .
Limi a ions o ou s udy include ha ou sample was pu posi ely
ec ui ed om one se ing, a childca e se ice, and ep esen s one
geog aphic loca ion, A lan a, GA. The sample comp ised o Whi e,
highly educa ed, highe -income mo he s om he Sou h. Thei
pe spec i es a e no gene alizable o o he mo he s. We ocused on
mo he s because hey end o bep ima y heal hca e decision-make s
o child en, including accina ions (41); howe e , no ha ing he
pe spec i es o a he s o o he ca egi e s limi s he conclusions
wecan d aw om ou indings. Ou s udy ook place a he beginning
o he accine ollou o child en ages 5–11 yea s, and i is possible
ha mo he s’ pe cep ions changed o e ime.
4.2 Fu u e ecommenda ions
Ou s udy demons a es he need o de elop ailo ed public
heal h in e en ions, accine policies, and clea and anspa en
communica ion s a egies o add ess he unique needs and conce ns
o subg oups o pa en s. Unde s anding how demog aphic ac o s,
such as ace, income, and educa ion, may in luence accine hesi ancy
may in o m di e en s a egies o shi a i udes and belie s owa d
accep ing childhood COVID-19 accines. Mo he s in ou s udy we e
in o med abou childhood COVID-19 accines by esea ching
scien i ic websi es, eading clinical ial in o ma ion, alking o
medical specialis s who we e hei iends and amilies, and
e iewing da a om go e nmen su eillance da abases. De eloping
an in e en ion ha could connec mo he s wi h medical and
in ec ious disease specialis s and scien is s may bebene icial in
add essing hei conce ns and coun e ing misin o ma ion. These
in e en ions could po en ially assis mo he s wi h in e p e ing
scien i ic in o ma ion accu a ely, including unde s anding he
limi a ions o su eillance sys ems. Mo he s in ou s udy did no ely
on social media as us ed sou ces o in o ma ion, and he e o e,
we ecommend p omo ing accine in o ma ion and engaging wi h
pa en s h ough hei p e e ed communica ion channels, such as
podcas s. Fu u e esea ch is wa an ed o s udy accine hesi ancy
pe spec i es o o he pa en s wi h highe educa ion and
socioeconomic s a uses and om di e en geog aphical egions o
see i simila pa e ns exis .
5 Conclusion
Vaccine hesi ancy may in luence a mo he ’s decision o delay o
e use o accina e hei child agains COVID-19 and may
be in luenced by demog aphic ac o s such as ace, income, and
educa ional a ainmen . Ou s udy highligh ed he unique accine
conce ns and needs o Whi e mo he s wi h highe educa ional and,
socioeconomic s a us an unde s udied g oup. Mos s udies ha e
ocused on he d i e o pa en al accine hesi ancy among acial and
e hnic mino i ies and hose wi h lowe socioeconomic s a us. Mo he s
in ou s udy conduc ed hei own esea ch and eached ou o
membe s o hei social ne wo k who we e medical specialis s such as
ca diologis s. They p e e ed discussing accine sa e y in o ma ion,
such as he po en ial long- e m e ec s, wi h hese specialis s a he
han hei pedia icians and p ima y ca e p o ide s. This is
conce ning, gi en ha p e ious s udies ha e ound ha
ecommenda ions om pedia icians a e he mos impac ul on
accine eceip (54). I sugges s he need o mo e ailo ed accine
communica ion s a egies and in e en ions, such as connec ing hese
pa en s wi h scien is s, epidemiologis s, and medical specialis s who
can answe hei ques ions and help hem unde s and he isk–bene i
a io o COVID-19 accines. Ou sample did no ely on social media
o accine in o ma ion, and policymake s may need o inc ease hei
p esence on al e na i e pla o ms, such as podcas s, o coun e
misin o ma ion. Vaccine-hesi an pa en s a e a he e ogeneous g oup,
and unde s anding he belie s, a i udes, and beha io s o
subpopula ions o pa en s is c i ical in educing accine hesi ancy and
inc easing COVID-19 accine up ake. Findings om ou s udy
e ealed ini ial pe cep ions o childhood COVID-19 accines o
child en ages 5–11 yea s and can in o m accina ion policies and
heal h p omo ion guidelines su ounding he in oduc ion o no el
accines o eme ging diseases.
Da a a ailabili y s a emen
The da ase s p esen ed in his a icle a e no eadily a ailable
because i consis s o audio and ideo eco dings o in e iews wi h
pa icipan s. Wewan o p o ec he con iden iali y and p i acy o he
pa icipan s. Upon eques wemay beable o p o ide summa ies.
69
Su agh e al. 10.3389/ pubh.2024.1355452
F on ie s in Public Heal h 08 on ie sin.o g
Reques s o access he da ase s should bedi ec ed o TS, i any.
[email p o ec ed].
E hics s a emen
The s udies in ol ing humans we e app o ed by he Ins i u ional
e iew boa d a UTHeal h Hous on (HSC-SPH-11-0577). The s udies
we e conduc ed in acco dance wi h he local legisla ion and
ins i u ional equi emen s. The pa icipan s p o ided hei w i en
in o med consen o pa icipa e in his s udy.
Au ho con ibu ions
TS: Concep ualiza ion, Da a cu a ion, Fo mal analysis, In es iga ion,
Me hodology, W i ing – o iginal d a , W i ing – e iew & edi ing. DA:
Fo mal analysis, W i ing – e iew & edi ing. PY: W i ing – e iew &
edi ing. MA: Concep ualiza ion, Fo mal analysis, Supe ision, W i ing
– e iew & edi ing. PC: Concep ualiza ion, Fo mal analysis,
Me hodology, Resou ces, Supe ision, W i ing – e iew & edi ing.
Funding
The au ho (s) decla e ha inancial suppo was ecei ed o he
esea ch, au ho ship, and/o publica ion o his a icle. TS was
suppo ed h ough a p edoc o al ellowship, he UTHeal h School o
Public Heal h-NCI Cance Con ol Resea ch T aining P og am
(Na ional Cance Ins i u e/T32CA057712, MPI: P. D. Mullen,
M. E. Fe nandez, S. W. Ve non).
Acknowledgmen s
We would like o acknowledge he pa icipan s o he s udy who
we e open o sha ing hei pe spec i es du ing he COVID-19
pandemic and She ly McCu dy om he Uni e si y o Texas Heal h
Science Cen e a Hous on (UTHeal h) School o Public Heal h,
Depa men o Heal h P omo ion and Beha io al Sciences, o
he guidance.
Con lic o in e es
The au ho s decla e ha he esea ch was conduc ed in he
absence o any comme cial o inancial ela ionships ha could
becons ued as a po en ial con lic o in e es .
Publishe ’s no e
All claims exp essed in his a icle a e solely hose o he au ho s
and do no necessa ily ep esen hose o hei a ilia ed
o ganiza ions, o hose o he publishe , he edi o s and he
e iewe s. Any p oduc ha may bee alua ed in his a icle, o claim
ha may bemade by i s manu ac u e , is no gua an eed o endo sed
by he publishe .
Re e ences
1. Wo ld Heal h O ganiza ion. Co ona i us. (2022). A ailable a : h ps://www.who.
in /heal h- opics/co ona i us (Accessed Decembe 1, 2023).
2. Ve i y R, Okell LC, Do iga i I, Winskill P, Whi ake C, Imai N, e al. Es ima es o
he se e i y o co ona i us disease 2019: a model-based analysis. Lance In ec Dis.
(2020) 20:669–77. doi: 10.1016/S1473-3099(20)30243-7
3. Wo ld Heal h O ganiza ion. Repo o he SAGE wo king g oup on accine hesi ancy.
(2014) A ailable a : h ps://www.asse -scienceinsocie y.eu/si es/de aul / iles/sage_wo king_
g oup_ e ised_ epo _ accine_hesi ancy.pd (Accessed, Decembe 2, 2023).
4. Shi DS, Whi ake M, Ma ks KJ, Anglin O, Milucky J, Pa el K, e al. Hospi aliza ions
o child en aged 5–11 yea s wi h labo a o y-con i med COVID-19 — COVID-NET, 14
s a es, ma ch 2020–Feb ua y 2022. MMWR Mo b Mo al Wkly Rep. (2022). A ailable
a : h ps://www.cdc.go /mmw / olumes/71/w /mm7116e1.h m (Accessed, May 25,
2024).
5. CDC. Cen e s o Disease Con ol and P e en ion. (2022). Bene i s o Ge ing a
COVID-19 Vaccine. A ailable a : h ps://www.cdc.go /co ona i us/2019-nco / accines/
accine-bene i s.h ml (Accessed, Decembe 1, 2023).
6. Commi ee on In ec ious Diseases. COVID-19 accines in in an s, child en, and
adolescen s. Pedia ics. (2022) 150:e2022058700. doi: 10.1542/peds.2022-058700
7. CDC. Cen e s o Disease Con ol and P e en ion. (2023). [ci ed 2023 Jan 10].
COVID Da a T acke . A ailable a : h ps://co id.cdc.go /co id-da a- acke (Accessed
May 27, 2024).
8. Uni ed S a es Food and D ug Adminis a ion. FDA au ho ized he eme gency use
o he P ize -BioNTech COVID-19 accine o he p e en ion o COVID-19 o include
child en 5 h ough 11 yea s o age. FDA; (2021). FDA Au ho izes P ize -BioNTech
COVID-19 Vaccine o Eme gency Use in Child en 5 h ough 11 Yea s o Age. A ailable
a : h ps://www. da.go /news-e en s/p ess-announcemen s/ da-au ho izes-p ize -
bion ech-co id-19- accine-eme gency-use-child en-5- h ough-11-yea s-age (Accessed,
May 27, 2024).
9. Valie MR, Elam-E ans LD, Mu Y, San ibanez TA, Yankey D, Zhou T, e al. Racial
and e hnic di e ences in COVID-19 accina ion co e age among child en and
adolescen s aged 5–17 yea s and pa en al in en o accina e hei child en — Na ional
Immuniza ion Su ey–Child COVID module, Uni ed S a es, Decembe 2020–
Sep embe 2022. MMWR Mo b Mo al Wkly Rep. (2023) 72:1–8. doi: 10.15585/mmw .
mm7201a1
10. Ka es J, Tolbe J, Rouw A. Upda e on COVID-19 Vaccina ion o 5–11 Yea Olds
in he U.S. (2022). Upda e on COVID-19 Vaccina ion o 5–11 Yea Olds in he U.S.
A ailable a : h ps://www.k .o g/co ona i us-co id-19/issue-b ie /upda e-on-co id-19-
accina ion-o -5-11-yea -olds-in- he-u-s/ (Accessed, Decembe 1, 2023).
11. B ewe NT, Chapman GB, Ro hman AJ, Leask J, Kempe A. Inc easing accina ion:
pu ing psychological science in o ac ion. Psychol Sci Public In e es . (2017) 18:149–207.
doi: 10.1177/1529100618760521
12. G oup, T.S.V.H.W. (2013). Wha in luences accine accep ance: a model o
de e minan s o accine hesi ancy.
13. Rane MS, Robe son MM, Wes mo eland DA, Teasdale CA, G o C, Nash D.
In en ion o accina e child en agains COVID-19 among accina ed and un accina ed
US pa en s. JAMA Pedia . (2022) 176:201–3. doi: 10.1001/jamapedia ics.2021.5153
14. Goulding M, Ryan GW, Minkah P, Bo g A, Gonzalez M, Medina N, e al. Pa en al
pe cep ions o he COVID-19 accine o 5- o 11-yea -old child en: ocus g oup
indings om Wo ces e Massachuse s. Hum Vaccin Immuno he . (2022) 18:2120721.
doi: 10.1080/21645515.2022.2120721
15. Walke KK, Head KJ, Owens H, Zime GD. A quali a i e s udy explo ing he
ela ionship be ween mo he s’ accine hesi ancy and heal h belie s wi h COVID-19
accina ion in en ion and p e en ion du ing he ea ly pandemic mon hs. Hum Vaccin
Immuno he . (2021) 17:3355–64. doi: 10.1080/21645515.2021.1942713
16. Humble RM, Sell H, Wilson S, Sada angani M, Be inge JA, Meye SB, e al.
Pa en s’ pe cep ions on COVID-19 accina ion as he new ou ine o hei child en ≤
11 yea s old. P e Med. (2022) 161:107125. doi: 10.1016/j.ypmed.2022.107125
17. Dubé E, Gagnon D, Pelle ie C. COVID-19 accina ion in 5-11 yea s old child en:
d i e s o accine hesi ancy among pa en s in Quebec. Hum Vaccin Immuno he . (2022)
18:2028516. doi: 10.1080/21645515.2022.2028516
18. Ngai CSB, Singh RG, Yao L. Impac o COVID-19 accine misin o ma ion on
social media Vi ali y: con en analysis o message hemes and w i ing s a egies. J Med
In e ne Res. (2022) 24:e37806. doi: 10.2196/37806
70
Su agh e al. 10.3389/ pubh.2024.1355452
F on ie s in Public Heal h 09 on ie sin.o g
19. Ruiz JB, Bell RA. Pa en al COVID-19 accine hesi ancy in he Uni edS a es. Public
Heal h Rep. (2022) 137:1162–9. doi: 10.1177/00333549221114346
20. Johnson NF, Velásquez N, Res epo NJ, Leahy R, Gab iel N, El Oud S, e al. The
online compe i ion be ween p o- and an i- accina ion iews. Na u e. (2020) 582:230–3.
doi: 10.1038/s41586-020-2281-1
21. Szilagyi PG, Shah MD, Delgado JR, Thomas K, Vizue a N, Cui Y, e al. Pa en s’
in en ions and pe cep ions abou COVID-19 accina ion o hei child en: esul s om
a Na ional Su ey. Pedia ics. (2021) 148:e2021052335. doi: 10.1542/peds.2021-052335
22. Fishe CB, G ay A, Sheck I. COVID-19 pedia ic accine hesi ancy among acially
di e se pa en s in he Uni ed S a es. Vaccine. (2022) 10:31. doi: 10.3390/
accines10010031
23. Teasdale CA, Bo ell LN, Kimball S, Rinke ML, Rane M, Flea y SA, e al. Plans o
accina e child en o co ona i us disease 2019: a su ey o Uni edS a es pa en s. J
Pedia . (2021) 237:292–7. doi: 10.1016/j.jpeds.2021.07.021
24. S olle LB, Nalamasu R, Pe golizzi JV, Va assi G, Magnusson P, LeQuang J, e al.
Fac s allacy: he an i- accine discussion eloaded. Ad The . (2020) 37:4481–90. doi:
10.1007/s12325-020-01502-y
25. Hussain A, Ali S, Ahmed M, Hussain S. The an i- accina ion mo emen : a
eg ession in mode n medicine. Cu eus. (2018). A ailable a : h ps://www.cu eus.com/
a icles/13250- he-an i- accina ion-mo emen -a- eg ession-in-mode n-medicine
(Accessed Decembe 3, 2023).
26. Malik AA, McFadden SM, Elha ake J, Ome SB. De e minan s o COVID-19
accine accep ance in he US. eClinicalMedicine. (2020). A ailable a : h ps://www.
helance .com/jou nals/eclinm/a icle/PIIS2589-5370(20)30239-X/ ull ex (Accessed
No embe 30, 2023).
27. Lu hy KE, Becks and RL, Callis e LC. Pa en al hesi a ion in immunizing child en
in U ah. Public Heal h Nu s. (2010) 27:25–31. doi: 10.1111/j.1525-1446.2009.00823.x
28. Spa ks G, Lopes L, Mon e o A, Hamel L, B odie M. KFF COVID-19 Vaccine
Moni o . (2022). A ailable a : h ps://www.k .o g/co ona i us-co id-19/poll- inding/
k -co id-19- accine-moni o -ap il-2022/ (Accessed May 24, 2024).
29. Honcoop A, Robe s JR, Da is B, Pope C, Dawley E, McCulloh RJ, e al. COVID-19
accine hesi ancy among pa en s: a quali a i e s udy. Pedia ics.
2023;152(5):e2023062466. Su on J, Aus in Z. Quali a i e esea ch: da a collec ion,
analysis, and managemen . Can J Hosp Pha m. (2015) 68:226–31.
30. Su on J, Aus in Z. Quali a i e esea ch: da a collec ion, analysis, and managemen .
Can J Hosp Pha m. (2015) 68:226–31. doi: 10.4212/cjhp. 68i3.1456
31. Baume -Mou adian SH, Ha RJ, Viso cky A, F ase R, P asad S, Le as M, e al.
Unde s anding in luenza and SARS-CoV-2 accine hesi ancy in acial and e hnic
mino i y ca egi e s. Vaccine. (2022) 10:1968. doi: 10.3390/ accines10111968
32. Schi J, Schmid AR, Pham PK, Pé ez JB, Panna aj PS, Chaudha i PP, e al.
Pa en al a i udes in he pedia ic eme gency depa men abou he COVID-19 accine.
Vaccine. (2022) 40:7328–34. doi: 10.1016/j. accine.2022.10.046
33. An oon JW, G ijal a CG, Thu m C, Richa dson T, Spaulding AB, Ii RJT, e al.
Fac o s associa ed wi h COVID-19 disease se e i y in US child en and adolescen s. J
Hosp Med. (2021) 16:603–10. doi: 10.12788/jhm.3689
34. DeJonckhee e M, Vaughn LM. Semis uc u ed in e iewing in p ima y ca e
esea ch: a balance o ela ionship and igou . Family Med. Commun. Heal h. (2019)
7:e000057. doi: 10.1136/ mch-2018-000057
35. Kallio H, Pie ilä AM, Johnson M, Kangasniemi M. Sys ema ic me hodological
e iew: de eloping a amewo k o a quali a i e semi-s uc u ed in e iew guide. J Ad
Nu s. (2016) 72:2954–65. doi: 10.1111/jan.13031
36. Bingham, AJ, and Wi kowsky, P. Deduc i e and induc i e app oaches o quali a i e
da a analysis. In C. Vano e , P. Mihas and J. Saldaña (edi o s), Analyzing and in e p e ing
quali a i e da a: A e he in e iew. SAGE Publica ions. (2022). 133–146.
37. B aun V, Cla ke V. Thema ic analysis In: APA handbook o esea ch me hods in
psychology, Vol 2: Resea ch designs: Quan i a i e, quali a i e, neu opsychological, and
biological. Washing on, DC, US: Ame ican Psychological Associa ion (2012). 57–71.
38. B aun V, Cla ke V. Using hema ic analysis in psychology. Qual Res Psychol. (2006)
3:77–101. doi: 10.1191/1478088706qp063oa
39. Fusch P, Ness L. A e we he e ye ? Da a sa u a ion in quali a i e esea ch. Qual
Rep. (2015) 20:1408–16. doi: 10.46743/2160-3715/2015.2281
40. Lahman MKE, Thomas R, Teman ED. A good name: pseudonyms in esea ch.
Qual Inq. (2023) 29:678–85. doi: 10.1177/10778004221134088
41. Gowda C, Dempsey AF. The ise (and all?) o pa en al accine hesi ancy. Hum
Vaccin Immuno he . (2013) 9:1755–62. doi: 10.4161/h .25085
42. Wa ne EL, Ding Q, Pappas LM, Hen y K, Kepka D. Whi e, a luen , educa ed
pa en s a e leas likely o choose HPV accina ion o hei child en: a c oss-sec ional
s udy o he Na ional Immuniza ion S udy – een. BMC Pedia . (2017) 17:200. doi:
10.1186/s12887-017-0953-2
43. Yang YT, Delama e PL, Leslie TF, Mello MM. Sociodemog aphic p edic o s o
accina ion exemp ions on he basis o pe sonal belie in Cali o nia. Am J Public Heal h.
(2016) 106:172–7. doi: 10.2105/AJPH.2015.302926
44. Khan, YH, Rasheed, M, Mallhi, TH, Salman, M, Alza ea, AI, Alanazi, AS, e al.
Ba ie s and acili a o s o childhood COVID-19 accina ion among pa en s: A
sys ema ic e iew. F on Pedia . (2022) 10:950406.
45. Olson O, Be y C, Kuma N. Add essing pa en al accine hesi ancy owa ds
childhood accines in he Uni edS a es: a sys ema ic li e a u e e iew o communica ion
in e en ions and s a egies. Vaccine. (2020) 8:590. doi: 10.3390/ accines8040590
46. Cohen AF, an Ge en J, Bu gos JG, de Boe A, Fouche RAM, Flo e H, e al.
COVID-19 accines: he impo ance o anspa ency and ac -based educa ion. B J Clin
Pha macol. (2020) 86:2107–10. doi: 10.1111/bcp.14581
47. T uong J, Bakshi S, Wasim A, Ahmad M, Majid U. Wha ac o s p omo e accine
hesi ancy o accep ance du ing pandemics? A sys ema ic e iew and hema ic analysis.
Heal h P omo In . (2022) 37. doi: 10.1093/heap o/daab105
48. Hayda o R, Go don JC. E ec o combining a ibu e and goal aming wi hin
messages o change accina ion beha io . J Commun Heal hc. (2015) 8:45–54. doi:
10.1179/1753807615Y.0000000005
49. Sabahelzain MM, Ha igan-Go K, La son HJ. The poli ics o Co id-19 accine
con idence. Cu Opin Immunol. (2021) 71:92–6. doi: 10.1016/j.coi.2021.06.007
50. Ki zinge A, Kea ney A, Hamel L, B odie M. KFF COVID-19 accine moni o : he
inc easing impo ance o pa isanship in p edic ing COVID-19 accina ion s a us.
(2021). KFF COVID-19 Vaccine Moni o : he Inc easing Impo ance o Pa isanship in
P edic ing COVID-19 Vaccina ion S a us. A ailable a : h ps://www.k .o g/co ona i us-
co id-19/poll- inding/impo ance-o -pa isanship-p edic ing- accina ion-s a us/
(Accessed Decembe 1, 2023).
51. Du kin LK, Flynn EM, Johnson ML, Da ies WH, G eenley RN. Vaccine a i udes
media e ela ionships be ween ca egi e poli ical ideology and likelihood o child
accina ion o COVID-19. Ma e n Child Heal h J. (2023) 27:984–90. doi: 10.1007/
s10995-023-03642-3
52. Joseph AM, Fe nandez V, K i zman S, Eaddy I, Cook OM, Lamb os S, e al.
COVID-19 misin o ma ion on social media: a scoping e iew. Cu eus. (2022) 14:e24601.
doi: 10.7759/cu eus.24601
53. Fai lie T, Chu B, Thomas ES, Que ns AK, Lyons A, Koziol M, e al. School-based
in e en ions o inc ease s uden COVID-19 accina ion co e age in public school
popula ions wi h low co e age — Sea le, Washing on, Decembe 2021–June 2022. Mo b
Mo al Wkly Rep. (2023) 72:283–7. doi: 10.15585/mmw .mm7211a3
54. Ja e C, Wilson R, O’Lea y M, Ecke sbe ge E, La son HJ. SAGE wo king g oup
on accine hesi ancy. S a egies o add essing accine hesi ancy- a sys ema ic e iew.
Vaccine. (2015) 33:4180–90. doi: 10.1016/j. accine.2015.04.040
55. Wei Z, Liu Y, Zhang L, Sun X, Jiang Q, Li Z, e al. S ages o HPV accine hesi ancy
among gua dians o emale seconda y school s uden s in China. J Adolesc Heal h. (2023)
72:73–9. doi: 10.1016/j.jadoheal h.2022.08.027
56. Lawes-Wickwa S, Ghio D, Tang MY, Keywo h C, S anescu S, Wes b ook J, e al.
A apid sys ema ic e iew o public esponses o heal h messages encou aging
accina ion agains in ec ious diseases in a pandemic o epidemic. Vaccine. (2021) 9:72.
doi: 10.3390/ accines9020072
57. Randolph HE, Ba ei o LB. He d immuni y: unde s anding COVID-19. Immuni y.
(2020) 52:737–41. doi: 10.1016/j.immuni.2020.04.012
71
F on ie s in Public Heal h 01 on ie sin.o g
Communi y Heal h Volun ee s’
expe iences o implemen ing
COVID-19 accine educa ion and
p omo ion in Kenya: a quali a i e
desc ip i e s udy
Cons ance S.Shumba
1
*, Pe e sonKi ai he
2, IsabelKambo
2 and
SheilaShaibu
2
1 Di ision o Epidemiology and Social Sciences, Ins i u e o Heal h and Equi y, Medical College o
Wisconsin, Milwaukee, WI, Uni ed S a es, 2 School o Nu sing and Midwi e y, Aga Khan Uni e si y,
Nai obi, Kenya
Backg ound: Vaccina ion was a key measu e in he COVID-19 pandemic
esponse, hough much wo k was needed o p omo e accine up ake and
accep ance. In Kenya, Communi y Heal h Volun ee s (CHVs) played a key ole
in accine educa ion and p omo ion. Weconduc ed his s udy o explo e CHVs’
expe iences o implemen ing COVID-19 accine educa ion and p omo ion
du ing he pandemic o inc ease COVID-19 accine up ake in wo a eas o
Kenya.
Me hods: In a quali a i e desc ip i e s udy, we conduc ed 30 s uc u ed in-
dep h in e iews wi h 20 CHVs and 10 Communi y Heal h Assis an s om u al
Kili i Coun y and Kangemi, an u ban in o mal se lemen o Nai obi Coun y in
Kenya be ween Ap il 2022 and July 2022.
Findings: Thema ic analysis gene a ed i e key hemes in ela ion o CHVs’
expe iences o implemen ing COVID-19 accine educa ion and p omo ion:
Fi e key hemes eme ged ega ding CHVs’ expe iences o implemen ing
COVID-19 accine educa ion and p omo ion: (1) accine p e e ences in luenced
accep ance, (2) he ea o side e ec s was a ba ie , (3) misin o ma ion was
widesp ead (4) lack o us in go e nmen and poli iciza ion o accines was a
ba ie , and (5) CHVs’ e o s we e a acili a o o inc eased up ake.
Conclusion: Ex ensi e communi y ou each om CHVs con ibu ed o he high
up ake o p ima y accines and boos e s du ing he COVID-19 pandemic. CHVs
ac ing as ole models by ecei ing accina ions i s was pa icula ly impo an
in in luencing communi ies o accep accina ions. Findings p o ide e idence
o p io i izing CHVs in he planning and implemen a ion o u u e accina ion
ini ia i es in Kenya and o he coun ies.
KEYWORDS
Communi y Heal h Volun ee s, COVID-19 accina ion, accine up ake, pandemic,
Kenya
OPEN ACCESS
EDITED BY
Ca los Albe o De Oli ei a Magalhães Júnio ,
S a e Uni e si y o Ma ingá, B azil
REVIEWED BY
Miguel Landa-Blanco,
Na ional Au onomous Uni e si y o Hondu as,
Hondu as
F. R. Lendacki,
Chicago Depa men o Public Heal h,
Uni edS a es
*CORRESPONDENCE
Cons ance S. Shumba
[email p o ec ed]
RECEIVED 25 Ma ch 2024
ACCEPTED 21 June 2024
PUBLISHED 10 July 2024
CITATION
Shumba CS, Ki ai he P, Kambo I and
Shaibu S (2024) Communi y Heal h
Volun ee s’ expe iences o implemen ing
COVID-19 accine educa ion and p omo ion
in Kenya: a quali a i e desc ip i e s udy.
F on . Public Heal h 12:1406959.
doi: 10.3389/ pubh.2024.1406959
COPYRIGHT
© 2024 Shumba, Ki ai he, Kambo and Shaibu.
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p ac ice. No use, dis ibu ion o ep oduc ion
is pe mi ed which does no comply wi h
hese e ms.
TYPE O iginal Resea ch
PUBLISHED 10 July 2024
DOI 10.3389/ pubh.2024.1406959
72
Shumba e al. 10.3389/ pubh.2024.1406959
F on ie s in Public Heal h 08 on ie sin.o g
wi h indi iduals who ha e been accina ed being encou aged o sha e
hei expe iences o inc ease us and con idence in he accine.
Communi y leade s and in luence s may play an impo an ole in
se ing a good example o o he s o ollow. Fu he , i is c ucial o
communica e possible ad e se eac ions and he s eps ha should
be aken in such ins ances.
Misin o ma ion was ano he ac o p e en ing accine up ake.
Repo s indica ed ha many belie ed COVID-19 o bea hoax, an
obse a ion ha is consis en wi h indings om Tanzania, Tu key,
and he U.S. (31–33). To add ess misin o ma ion and disin o ma ion,
public heal h o icials and heal hca e p ac i ione s mus p io i ize he
dis ibu ion o co ec in o ma ion. Inco ec belie s can bedispelled
by wo king wi h communi y leade s and in luence s o deli e clea
in o ma ion ega ding accina ion bene i s and sa e y. Open o ums
and educa ional wo kshops, o example, can add ess conce ns and
gi e e idence-based esponses o enable in o med accina ion
decision-making. Accu a e in o ma ion, communi y pa icipa ion,
and compassiona e communica ion can help imp o e public
heal h ou comes.
Lack o us in he go e nmen was also a majo hu dle, acco ding
o CHVs. This is consis en wi h indings om a s udy conduc ed
ac oss coun ies which ound Kenya o ank highes in he co ela ion
be ween lack o us in he go e nmen and non-accep ance o he
accine (34). A simila associa ion has been shown in China (35, 36).
Belie in conspi acy heo ies, such as accines being s a e-backed
in e en ions, dec eased us in accines and es ic ed up ake (37,
38). I is impo an ha us be ween go e nmen and ci izens is
con inuously cul i a ed and ha s eps a e aken o add ess sou ces o
mis us . Campaigns o depoli icize accina ion can help es o e ai h
in go e nmen ac ion. Rela ionships be ween communi ies and
us ed wo ke s such as CHVs can be i al in his endea o .
Findings indica ed ha CHVs we e igh ly p io i ized o
COVID-19 accina ion alongside o he on line heal h wo ke s. This
is consis en wi h WHO guidance (4). CHVs we e ac i ely in ol ed in
p omo ing accine up ake, wi h mos epo ing up ake a es o 80%
and abo e in hei communi ies. Thei pa icipa ion in p omo ing
accina ion, conduc ing sensi iza ion p og ams, and p o iding
accu a e in o ma ion had a subs an ial in luence. Th ough being
p io i ized, hey we e able o ole-model being accina ed and
encou age communi ies o also do he same. Simila ly, in o he
con ex s, by highligh ing he impo ance o COVID-19 accines and
showing con idence in hem, CHWs posi i ely impac ed communi y
up ake (4, 14), wi h e idence suppo ing ha accina ed heal hca e
wo ke s a e mo e likely han un accina ed ones o encou age he
public o ecei e accina ion (14, 39). CHVs also engaged wi h he
communi y as us ed membe s o deli e accu a e in o ma ion on
COVID-19 accina ion up ake and sha ing success s o ies o CHVs
who had ecei ed he accine was impo an in inc easing accina ion
up ake and coun e ac ing un a o able na a i es. An implica ion is
ha accina ion hesi ancy can be ackled h ough ocused
communica ion echniques.
S eng hs and limi a ions
This s udy con ibu es o a signi ican esea ch gap ega ding
LMICs such as Kenya whe e he expe ience o CHVs in p omo ing
COVID-19 accine up ake is no well-s udied. The ques ions
co e ed du ing he in e iews enabled es ablishmen o appo ,
and guided obus unde s anding o he o e all wo k o CHVs
du ing he pandemic and how hey expe ienced hei wo k wi h
communi ies speci ically in p omo ing COVID-19 accine up ake.
Ou indings ha e he po en ial o guide he de elopmen o isk
communica ion and communi y engagemen ma e ials and
in o m guidelines and policies on accine up ake and accep ance,
no only du ing pandemics bu also in ou ine immuniza ion
p og ams. Rec ui men o u ban and u al pa icipan s is also a
s eng h o ou s udy and o each heme, a compa ison o he
indings be ween he wo dis inc geog aphical a eas has
been made.
Despi e hese s eng hs, in e p e a ion o ou indings may
belimi ed by he s udy being conduc ed in jus wo o 47 coun ies in
Kenya. Also, he e is di e si y in he expe iences o CHVs and ou
indings may no e lec he pe spec i es o all CHVs ac oss he
coun y. Tha said, al hough indings may no begene alizable o he
en i e coun y, hey migh be ans e able. Fu he mo e, al hough
we did da a sou ce iangula ion be ween CHVs and CHAs, a
limi a ion was he lack o iangula ion o co obo a e indings om
CHVs wi h hose om communi y membe s. Rep esen a ion o
communi ies’ own na a i es would ha e deepened unde s anding o
how accine educa ion and p omo ion was expe ienced by
communi y membe s and would ha e enhanced he c edibili y and
alidi y o ou s udy indings. In addi ion, a limi a ion o no e is ha
he e was no p e/pos -in e en ion s udy o measu emen he e o
e alua e whe he use o CHVs was associa ed wi h imp o ed
accine co e age.
Fu u e esea ch should ocus on building upon he indings o his
explo a ion, po en ially deploying a mixed me hods app oach.
Fu he , u u e s udies should ocus on co-c ea ing and es ing he
easibili y o isk communica ion and communi y engagemen models
led by CHVs and hei communi ies, ha ha e a highe likelihood o
success in inc easing adop ion o global guidance and add essing he
ba ie s uniquely iden i ied in he pandemic con ex .
Conclusion and ecommenda ions
This s udy a i ms he impo an ole CHVs played in mobilizing
communi ies o ake up p ima y accines and boos e s du ing he
pandemic h ough accine educa ion and p omo ion. CHVs ac ing as
ole models by ecei ing accina ions i s was a pa icula ly s ong
d i e o communi y up ake. Ou indings suppo he need o ailo
isk communica ion and communi y engagemen o add ess my hs
and misconcep ions, while also le e aging ac o s ha can p omo e
accina ion up ake such as he es ablished posi i e and us ed
ela ionships wi h CHVs. Fu he , he indings demons a e he
impo ance o p io i izing CHVs in he planning and implemen a ion
o u u e accina ion ini ia i es in Kenya and simila coun ies.
Finally, he indings e eal unde lying issues o public us owa d
accina ion d i es. This poin s o he c ucial ole o con inual
educa ion and awa eness aising in communi ies on he impo ance
o accines, inc easing he likelihood o accine up ake in si ua ions
o heal h c isis such as COVID-19.
79
Shumba e al. 10.3389/ pubh.2024.1406959
F on ie s in Public Heal h 09 on ie sin.o g
Da a a ailabili y s a emen
The o iginal con ibu ions p esen ed in he s udy a e included in
he a icle/supplemen a y ma e ial, u he inqui ies can bedi ec ed
o he co esponding au ho .
E hics s a emen
The s udies in ol ing humans we e app o ed by Aga Khan Kenya’s
Ins i u ional Scien i ic and E hics Re iew Commi ee [Re : 2020/
IERC-89( 3)] and he Na ional Commission o Science Technology
and Inno a ion (EOP/NMS/HS/088). The s udies we e conduc ed in
acco dance wi h he local legisla ion and ins i u ional equi emen s.
The pa icipan s p o ided hei w i en in o med consen o
pa icipa e in his s udy.
Au ho con ibu ions
CS: Concep ualiza ion, Fo mal analysis, Funding acquisi ion,
Me hodology, Valida ion, W i ing – o iginal d a , W i ing – e iew &
edi ing. PK: Da a cu a ion, Fo mal analysis, In es iga ion, Valida ion,
W i ing – e iew & edi ing. IK: Me hodology, Valida ion, W i ing
– e iew & edi ing. SS: Concep ualiza ion, Funding acquisi ion,
Me hodology, Supe ision, Valida ion, W i ing – e iew & edi ing.
Funding
The au ho (s) decla e ha no inancial suppo was ecei ed o
he esea ch, au ho ship, and/o publica ion o his a icle.
Con lic o in e es
The au ho s decla e ha he esea ch was conduc ed in he
absence o any comme cial o inancial ela ionships ha could
becons ued as a po en ial con lic o in e es .
Publishe ’s no e
All claims exp essed in his a icle a e solely hose o he au ho s
and do no necessa ily ep esen hose o hei a ilia ed o ganiza ions,
o hose o he publishe , he edi o s and he e iewe s. Any p oduc
ha may bee alua ed in his a icle, o claim ha may bemade by i s
manu ac u e , is no gua an eed o endo sed by he publishe .
Re e ences
1. WHO. (2023). Co ona i us disease (COVID-19). 9 Augus 2023. A ailable a :
h ps://www.who.in /news- oom/ ac -shee s/de ail/co ona i us-disease-(co id-19)
(Accessed Ap il 18, 2023)
2. Spi e i G, Fielding J, Die cke M, Campese C, Enou V, Gayma d A, e al. Fi s cases
o co ona i us disease 2019 (COVID-19) in he WHO Eu opean egion, 24 Janua y o
21 Feb ua y 2020. Eu o Su eill. (2020) 25:2000178. doi: 10.2807/1560-7917.
ES.2020.25.9.2000178
3. WHO (2023). Kenya. A ailable a h ps://www.who.in /coun ies/ken (Accessed
Ap il 18, 2024)
4. Wo ld Heal h O ganiza ion and he Uni ed Na ions Child en’s Fund (UNICEF).
The ole o communi y heal h wo ke s in COVID-19 accina ion implemen a ion
suppo guide, 26 Ap il 2021. Gene a: Wo ld Heal h O ganiza ion (2021).
5. O angi S, Mbu hia D, Chondo E, Ngunu C, Kabia E, Ojal J, e al. A quali a i e
inqui y on d i e s o COVID-19 accine hesi ancy among adul s in Kenya. PLOS Glob
Public Heal h. (2024) 4:e0002986. doi: 10.1371/jou nal.pgph.0002986
6. Johns Hopkins Uni e si y and Medicine. (2024). Co ona i us esou ce cen e .
Kenya. A ailable a : h ps://co ona i us.jhu.edu/ egion/kenya (Accessed Ap il 17, 2024)
7. Kunyenje CA, Chi wa GC, Mboma SM, Ng'ambi W, Mnjowe E, Nkhoma D, e al.
COVID-19 accine inequi y in A ican low-income coun ies. F on Public Heal h.
(2023) 11:1087662. doi: 10.3389/ pubh.2023.1087662
8. Lawal L, Aminu Bello M, Mu wi a T, A oka C, Yusu Ma'a u S, Ha ison
Omonhinmin I, e al. Low co e age o COVID-19 accines in A ica: cu en e idence
and he way o wa d. Hum Vaccin Immuno he . (2022) 18:2034457. doi:
10.1080/21645515.2022.2034457
9. Ndu M, Andoniou E, McNally S, Olea Popelka F, Tippe M, Nou e E. The
expe iences and challenges o communi y heal h olun ee s as agen s o beha iou
change p og amming in A ica: a scoping e iew. Glob Heal h Ac ion. (2022) 15:2138117.
doi: 10.1080/16549716.2022.2138117
10. Balla d M, Ode a M, Bha S, Geo ey B, Wes ga e C, Johnson A. Paymen o
communi y heal h wo ke s. Lance Glob Heal h. (2022) 10:e1242. doi: 10.1016/
S2214-109X(22)00311-4
11. Minis y o Heal h (2014). S a egy o communi y heal h 2014-2019 ans o ming
heal h: accele a ing he a ainmen o heal h goals. A ailable a : h p://guidelines.heal h.
go.ke:8000/media/STRATEGY_FOR_COMMUNITY_HEALTH_2014-2019.pd
(Accessed May 25, 2023)
12. Osu J, Muinga E, Ca e J, Ku ia S, Hussein S, I e i EM. COVID-19 accine
hesi ancy: accina ion in en ion and a i udes o communi y heal h olun ee s in Kenya.
PLOS Glob Public Heal h. (2022) 2:e0000233. doi: 10.1371/jou nal.pgph.0000233
13. Lusambili AM, Nyanja N, Chabeda SV, Temme man M, Nyaga L, Obu e J, e al.
Communi y heal h olun ee s’ challenges and p e e ed income gene a ing ac i i ies o
sus ainabili y: a quali a i e case s udy o u al Kili i, Kenya. BMC Heal h Se Res. (2021)
21:642. doi: 10.1186/s12913-021-06693-w
14. Bassi S, Bahl D, Thapliyal N, Mai y H, Ma a he SD, P akshale BB, e al. COVID-19
accine knowledge, a i udes, pe cep ions, and up ake among heal hca e wo ke s o
Pune dis ic , Maha ash a. J Global Heal h Repo s. (2022) 6:e2022041. doi:
10.29392/001c.37242
15. I e i EM, Mu ugi MW, Falisse JB, Mwi a i JM, A ambo LK. In luence o conspi acy
heo ies and dis us o communi y heal h olun ee s on adhe ence o COVID-19
guidelines and accine up ake in Kenya. PLOS Glob Public Heal h. (2023) 3:e0001146.
doi: 10.1371/jou nal.pgph.0001146
16. Hun e D, McCallum J, Howes D. De ining explo a o y-desc ip i e quali a i e
(EDQ) esea ch and conside ing i s applica ion o heal hca e. J Nu s Heal h Ca e.
(2019) 4.
17. Sandelowski M. Focus on esea ch me hods wha e e happened o quali a i e
desc ip ion? Res Nu s Heal h. (2000) 23:334–40. doi: 10.1002/1098-240X(200008)23:4
<334::AID-NUR9>3.0.CO;2-G
18. Ngugi AK, Odhiambo R, Agoi F, Lakhani A, O wa J, Obu e J. Mang’ong’o D,
Luch e s S, Munywoki C, Oma a, Temme man M, coho p o ile: he Kaloleni/Rabai
communi y heal h and demog aphic su eillance sys em. In J Epidemiol. (2020) 49:758–
759e. doi: 10.1093/ije/dyz252
19. Nyasani DK, Mu ua GN, Sajabi RM, Ng'ang'a JW, Gachie JN, Maina AM, e al.
Repo ed willingness o pa icipa e in a hypo he ical HIV accine ial and i s ansla ion
o ac ual pa icipa ion among heal hy adul s-expe ience om Kenya. PLoS One. (2018)
13:e0206656. doi: 10.1371/jou nal.pone.0206656
20. Masenge V, Osabwa E. Changing li es in Kangemi: he impac o Upendo and Uzima
sa egua ding p ojec s in Nai obi’s slum, Kenya. Re lec ion. (2024). PI 136, p. 43–46.
21. Hennink M, Kaise BN. Sample sizes o sa u a ion in quali a i e esea ch: a
sys ema ic e iew o empi ical es s. Soc Sci Med. (2022) 292:114523:ISSN 0277-9536.
doi: 10.1016/j.socscimed.2021.114523
22. Minis y o Heal h. Taking he Kenya essen ial package o heal h o he communi y:
A s a egy o he deli e y o le el one se ices. Nai obi: Minis y o Heal h (2006).
23. B aun V, Cla ke V. Using hema ic analysis in psychology. Qual Res Psychol. (2006)
3:77–101. doi: 10.1191/1478088706qp063oa
24. Ca e N, B yan -Lukosius D, DiCenso A, Bly he J, Ne ille AJ. The use o
iangula ion in quali a i e esea ch. Oncol Nu s Fo um. (2014) 41:545–7. doi:
10.1188/14.ONF.545-547
80
Shumba e al. 10.3389/ pubh.2024.1406959
F on ie s in Public Heal h 10 on ie sin.o g
25. Kaise K. P o ec ing esponden con iden iali y in quali a i e esea ch. Qual Heal h
Res. (2009) 19:1632–41. doi: 10.1177/1049732309350879
26. Dahi AL (2021). Vaccine hesi ancy uns high in some A ican coun ies, in some
cases lea ing unused doses o expi e. New Yo k Times. A ailable a : h ps://www.
ny imes.com/2021/04/16/wo ld/ accine-hesi ancy-a ica.h ml (Accessed June 9, 2024)
27. Coope S, an Rooyen H, Wiysonge CS. COVID-19 accine hesi ancy in
Sou hA ica: how can wemaximize up ake o COVID-19 accines? Expe Re Vaccines.
(2021) 20:921–33. doi: 10.1080/14760584.2021.1949291
28. O angi S, Pincho J, Mwanga D, Abuya T, Hamaluba M, Wa imwe G, e al.
Assessing he le el and de e minan s o COVID-19 accine con idence in Kenya.
Vaccine. (2021) 9:936. doi: 10.3390/ accines9080936
29. Solís A ce JS, Wa en SS, Me iggi NF, Scacco A, McMu y N, Voo s M, e al.
COVID-19 accine accep ance and hesi ancy in low- and middle-income coun ies. Na
Med. (2021) 27:1385–94. doi: 10.1038/s41591-021-01454-y
30. UNICEF (2021). Kenya: Success ul launch o a pa ne ship wi h eligious leade s.
SBC newsle e . A ailable a : h ps://si es.google.com/ iew/unice -esa o-c4d-newsle e /
eb ua y-2022/kenya-success ul-launch-o -a-pa ne ship-wi h- eligious-leade s
(Accessed June 10, 2024)
31. Zimme man T, Shi oma K, Fleischmann KR, Xie B, Jia C, Ve ma N, e al.
Misin o ma ion and COVID-19 accine hesi ancy. Vaccine. (2023) 41:136–44. doi:
10.1016/j. accine.2022.11.014
32. M enga S, Mhalu G, Ose insky B, Ramaiya K, Kassim T, Hooley B, e al. Social-
poli ical and accine ela ed de e minan s o COVID-19 accine hesi ancy in Tanzania:
a quali a i e inqui y. PLOS Global Public Heal h. (2023) 3:e0002010. doi: 10.1371/
jou nal.pgph.0002010
33. Imho R, Lambe y P. A bioweapon o a hoax? The link be ween dis inc
conspi acy belie s abou he co ona i us disease (COVID-19) ou b eak and pandemic
beha io . Soc Psychol Pe sonal Sci. (2020) 11:1110–8. doi: 10.1177/1948550620934692
34. Da is TP J , Yimam AK, Kalam MA, Tolossa AD, Kanwagi R, Baule S, e al.
Beha iou al de e minan s o COVID-19- accine accep ance in u al a eas o six lowe -
and middle-income coun ies. Vaccine. (2022) 10:214. doi: 10.3390/ accines10020214
35. Du F, Chan le T, F ancis MR, Sun FY, Zhang X, Han K, e al. The de e minan s o
accine hesi ancy in China: a c oss-sec ional s udy ollowing he Changchun
Changsheng accine inciden . Vaccine. (2020) 38:7464–71. doi: 10.1016/j.
accine.2020.09.075
36. Liu PL, Zhao X, Wan B. COVID-19 in o ma ion exposu e and accine hesi ancy:
he in luence o us in go e nmen and accine con idence. Psychol Heal h Med. (2023)
28:27–36. doi: 10.1080/13548506.2021.2014910
37. Ha ing on J, Ngi a D. Is Kenya eady? Human igh s, COVID-19 and accine
p epa edness. London: Royal A ican Socie y (2021).
38. Oyeyemi S, Fagbemi S, Busa i I, Wynn R. Belie in COVID-19 conspi acy heo ies,
le el o us in go e nmen in o ma ion, and willingness o ake COVID-19 accines
among heal h ca e wo ke s in Nige ia: su ey s udy. JMIR Fo m Res. (2023) 7:e41925.
doi: 10.2196/41925
39. Shekha R, Sheikh AB, Upadhyay S, Singh M, Ko ewa S, Mi H, e al. COVID-19
accine accep ance among heal h ca e wo ke s in he Uni edS a es. Vaccine. (2021)
9:119. doi: 10.3390/ accines9020119
81
F on ie s in Public Heal h 01 on ie sin.o g
One Heal h educa ion o
c i icali y on accina ion in
eache aining
InésMa ínez-Pena
1
*, BlancaPuig
1 and A ai zUskola
2
1 Facul y o Educa ion, Uni e sidade de San iago de Compos ela (USC), San iago, Spain, 2 Depa men
o Didac ics o Ma hema ics and o Expe imen al and Social Sciences, Uni e si y o he Basque
Coun y (UPV/EHU), Leioa, Spain
In oduc ion: Vaccines a e he basis o heal h o ou communi ies since hey
p e en se e e in ec ious diseases. Howe e accina ion a es con inue o
dec ease due o he sp ead o misin o ma ion abou hei side e ec s, which
enhances accine hesi ancy and pu s a isk public heal h. In oducing accines
om he One Heal h app oach can help o de elop an in eg al unde s anding
o hei ole and o apply c i ical igno ance as pa o c i icali y o a oid accine
hesi ancy and aise us in science. This pape p esen s a design on accina ion
o seconda y-educa ion eache aining de eloped owa d his goal.
Me hods: The design p esen ed in his pape d aws om p e ious s udies on
c i ical hinking, on accine ejec ion, and he One Heal h app oach on o he
heal h issues in Seconda y Educa ion. The ocus o his design is engaging
seconda y-educa ion p e-se ice eache s in he p ac ice o c i ical igno ance
and c i icali y o assess di e se pieces o in o ma ion on accina ion om he
One Heal h app oach.
Resul s: This s udy discusses he design p inciples and he ac i i ies o an o iginal
design ha aims o p o ide Seconda y Educa ion eache s wi h some ools o
in oduce c i ical igno ance and c i icali y o add essing misin o ma ion on
accines by using he One Heal h app oach.
Discussion: I seconda y science eache s a e going o success ully con on
misin o ma ion on accina ion in hei science ins uc ion, we need o
de elop and es designs and app oaches ha p epa e hem o his pu pose.
C i ical igno ance plays a cen al ole in managing misin o ma ion; hus, such
ins uc ion should engage u u e eache s in c i ical e alua ion o in o ma ion
on accina ion, as well as in he applica ion o he One Heal h app oach o ake
esponsible ac ions.
KEYWORDS
One Heal h, accines, c i icali y, c i ical igno ing, biology educa ion, eache aining
1 In oduc ion
Since hei disco e y accines ha e con ibu ed o sa e millions o li es h oughou
His o y and allowed he e adica ion o de as a ing diseases (1, 2). Recen ly, he COVID-19
pandemic highligh ed he ele ance o accina ion. I is es ima ed ha COVID-19 accines
con ibu ed o sa e a ound 1.4 million li es in Eu ope be ween Decembe 2020 and Ma ch
2023 (3).
OPEN ACCESS
EDITED BY
G aça S. Ca alho,
Uni e si y o Minho, Po ugal
REVIEWED BY
Becky Spa ks-Thissen,
Uni e si y o Sou he n Indiana, Uni edS a es
Gaganjyo Kau ,
Gu u Nanak Khalsa College o A , Science
and Comme ce, India
*CORRESPONDENCE
Inés Ma ínez-Pena
[email p o ec ed]
RECEIVED 29 Ma ch 2024
ACCEPTED 11 July 2024
PUBLISHED 26 July 2024
CITATION
Ma ínez-Pena I, Puig B and Uskola A (2024)
One Heal h educa ion o c i icali y on
accina ion in eache aining.
F on . Public Heal h 12:1408965.
doi: 10.3389/ pubh.2024.1408965
COPYRIGHT
© 2024 Ma ínez-Pena, Puig and Uskola. This
is an open-access a icle dis ibu ed unde
he e ms o he C ea i e Commons
A ibu ion License (CC BY). The use,
dis ibu ion o ep oduc ion in o he o ums is
pe mi ed, p o ided he o iginal au ho (s) and
he copy igh owne (s) a e c edi ed and ha
he o iginal publica ion in his jou nal is ci ed,
in acco dance wi h accep ed academic
p ac ice. No use, dis ibu ion o ep oduc ion
is pe mi ed which does no comply wi h
hese e ms.
TYPE Cu iculum, Ins uc ion, and
Pedagogy
PUBLISHED 26 July 2024
DOI 10.3389/ pubh.2024.1408965
82
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Despi e he ele ance o accines o p ese e heal h, he e is a
conce ning g ow h o accine hesi ancy among popula ion (4). This
is os e ed by he quick sp ead o allacies and ake-news and inc eases
he likelihood o p e en able-disease ou b eaks. Educa ion in accines
is an essen ial ool o aise awa eness abou he impo ance o
accina ion and o igh agains misin o ma ion. Unde s anding how
accines wo k and why hey a e impo an is a complex ask ha
equi es conside ing se e al dimensions o he p oblem besides
human heal h. Consequen ly, accine educa ion should in eg a e
app oaches ha allow he de elopmen o a global iew o he
p oblem. One Heal h (OH) is an app oach ha conside s he heal h
o humans, animals, and ecosys ems as in e dependen , p o iding a
global iew o complex heal h issues, such as accina ion.
Assessing accina ion and managing misin o ma ion also equi es
he applica ion o c i ical hinking (CT) skills, especially, c i ical
igno ing (CI) and c i icali y. CI is he abili y o selec he in o ma ion,
and a oid low-quali y in o ma ion o con ol own’s in o ma ional
en i onmen (5). This will help ci izens no only o de elop hei own
opinion based on scien i ic e idence, and o di e en ia e e idence-
based in o ma ion om pseudoscien i ic claims, bu also o ake
ac ions acco ding o hei opinion, pu ing CT in p ac ice by
commi ing o indi idual and collec i e ac ions, as he concep o
c i icali y poin s ou .
The li e a u e e iew showed ha mos app oaches ha in oduce
accina ion in heal h educa ion limi o ocus on human heal h,
wi hou conside ing en i onmen al ac o s ha a ec his issue (6).
This s udy seeks o make a ele an con ibu ion on his and is in line
wi h cu en ends ega ding he unde s anding o heal h as a global
issue ha no only in ol es humans, bu also he heal h o animals,
plan s and ecosys ems, a iew ha is cohe en wi h he OH app oach
(7). This design seeks o help eache s o p omo e an in eg al OH iew
o accina ion, and o use eaching s a egies o managing
in o ma ion and o make esponsible ac ions.
2 Didac ical amewo k
2.1 Educa ional challenges o p omo e
c i icali y on accina ion
E en hough he bene i s o accina ion a e widely suppo ed by
scien i ic e idence, accine hesi ancy is a cu en conce n in ou
socie y. Vaccine hesi ancy was de ined by he Wo ld Heal h
O ganiza ion (WHO) S a egic Ad iso y G oup o Expe s (SAGE) on
Immuniza ion as:
“Vaccine hesi ancy e e s o delay in accep ance o e usal o accines
despi e a ailabili y o accina ion se ices. Vaccine hesi ancy is
complex and con ex speci ic a ying ac oss ime, place and accines.
I includes ac o s such as complacency, con enience and con idence.”
(8) (p.575).
Vaccine hesi ancy includes people who show low o no con idence
in accines bu may suppo accina ion in ce ain si ua ions and/o
con ex s. An i- accine mo emen s a e loca ed on one ex eme o he
con inuum o accine hesi ancy. An i- accine indi iduals deny he
e icacy o accines, o ally ejec ing hei use independen ly on he
con ex and ci cums ances (9).
One o he main conce ns o accine-hesi an s and an i- accine
indi iduals is he sa e y o accines (10). This lack o us is enhanced
by he sp ead o allacies wi h no scien i ic e idence (e.g., accines
cause au ism, con ain compounds ha poison us, i is be e he
na u al immuni y han he immuni y gene a ed by accines, mRNA
accines modi y ou genome…) (11, 12).
In he pos - u h e a, accine misconcep ions and ake news a e
quickly sp ead by social media p omo ing hesi ancy (4, 13). This leads
o a educ ion in accine co e age among he popula ion inc easing
he isk o p e en able-disease ou b eaks. Diseases ha ha e long
ceased o bea p oblem (e.g., measles) a e cu en ly expe iencing
ou b eaks due o unde accina ion in de eloped coun ies like he US
and Eu ope (14, 15).
This also shows he exis ence o a educing le el o us in science.
The low us in science migh beenhanced by a wide ange o ac o s,
such as complex and abs ac scien i ic ocabula y, low abili y o
manage he unce ain y inhe en o he cons uc ion o scien i ic
knowledge, and he lack o knowledge ega ding he Na u e o Science.
Mo eo e , he sp ead o ake news a ec s how people deal wi h
scien i ic in o ma ion. Science educa o s seek o p omo e us in
science aking in o conside a ion hese challenges, as well as
misconcep ions ha ha e been al eady iden i ied in he li e a u e on
accina ion (12). This design aims o p o ide eache s wi h ools o
in oduce e icien s a egies o managing in o ma ion o a oid
misin o ma ion and p omo e us in science.
2.2 OH educa ion o he p ac ice o
c i icali y in he con ex o accina ion
Raising awa eness abou accina ion and educing hesi a ion is
one o he main goals in heal h educa ion. Heal h educa ion is pa o
he biology cu iculum in Seconda y Educa ion (12–16 yea s old) in
ou coun y (blinded o e iew). Howe e , heal h p oblems ha e been
in oduced as human cen e ed SSIs, wi hou an explici connec ion
wi h he en i onmen . In esponse o his, and acco ding o he new
science cu iculum (blinded o e iew) ha includes he OH
app oach, science educa o s need o p omo e heal h educa ion om
a sys emic pe spec i e aligned wi h he OH app oach o imp o e
eache s’ and s uden s’ unde s anding o accina ion om an in eg al
iew (16–18). This is he app oach ollowed in his design.
A deep unde s anding o he socio-scien i ic dimensions o
accina ion and hei po en ial o keep he heal h o a communi y
equi es he de elopmen o he OH app oach. OH claims ha he
heal h o humans, animals, and ecosys ems (including plan s) a e
closely in e dependen (7). In oducing he OH app oach o each
accina ion will allow o comp ehend he impac a di e en le els
de i ed om an indi idual ac ion ( e use accina ion). Such
consequences would bedi icul o iden i y om a human-cen e ed
ision. Tackling heal h p oblems om he OH app oach equi es
coo dina ion be ween di e en social and p o essional sec o s,
including educa ion. In ac , he e a e cu en ini ia i es o assess
accina ion om he OH app oach (19) bu ew o hem a e being
de eloped in science and heal h educa ion.
Teaching he impo ance o accines should beo ien ed owa d
empowe ing s uden s o make in o med decisions and ake indi idual
and collec i e ac ions (10). This is an essen ial pa o heal h li e acy
and c i icali y. A high de elopmen o heal h li e acy equi es he
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de elopmen o CT o ien ed o ac ion, which co esponds o he
no ion o c i icali y.
The CT is essen ial o deeply unde s and complex phenomena,
allowing he de elopmen o an independen opinion, hus
empowe ing s uden s (20). As shown by Au ho s (blinded) (10),
p omo ing CT skills along wi h knowledge abou accines would help
s uden s o pe o m be e decision-making and de elop ac ions
acco ding o cu en scien i ic knowledge, a oiding pseudoscien i ic
and non-scien i ic p emises.
As Da ies and Ba ne (21) poin ed ou , eaching CT in highe
educa ion in ol es conside ing a leas six CT dimensions: (1) co e
skills in c i ical a gumen a ion ( easoning and in e ence making); (2)
c i ical judgemen s; (3) CT disposi ions and a i udes; (4) c i ical
being and c i ical ac ions; (5) socie al and ideology c i ique; (6) c i ical
c ea i i y o c i ical openness. This wo k is ocused on he second
dimension, since c i ical judgmen is essen ial o a sui able decision-
making, and he ou h dimension as i is he mos ela ed o c i icali y.
The e m c i icali y in ol es CT and a ends o he indi idual
iden i y and he c i ical ac ion dimension (21). C i icali y p omo ion
among s uden s equi es he de elopmen o complex and global iews
ega ding an issue and wea gue ha OH could p o ide he in eg a ed
iew equi ed o e ec i ely de elop c i icali y ega ding accina ion.
Decision-making and ac ion de elopmen equi e di e en ia ing
u h ul in o ma ion om non-scien i ic ideas. Fo his, c i ical
igno ance (CI) is essen ial (22). CI can bede ined as he conscious
decision abou igno ing pa o in o ma ion delibe a ely by selec ing
and il e ing in o ma ion o minimize he exposu e o low-quali y
in o ma ion (5). Al hough CI is undamen al in he pos - u h e a,
mos o he li e a u e on accines and CT a e based on knowledge and
e idence-based a gumen a ion o encou age c i ical decision-making.
Despi e ag eeing ha some ex en o undamen al knowledge is
needed o CT applica ion, i is no always possible o s uden s o
ha e a highly-speci ic knowledge on each SSI. This is some hing ha
Seconda y Educa ion eache s should ake in o conside a ion and ha
his design add esses.
The e o e, i is necessa y o p o ide ins uc ion o p e-se ice/
in-se ices Seconda y Educa ion eache s abou how o de elop he
OH app oach ega ding accina ion o os e CI, and C i icali y
among hei s uden s.
3 Lea ning en i onmen
3.1 Lea ning objec i e
The objec i e o his design is o engage Seconda y Educa ion
p e-se ice eache s in he p ac ice o c i icali y wi h a ocus on CI o
assess in o ma ion on accina ion om he OH app oach. Speci ically,
i is aimed o:
1. Explo e how OH in luences he unde s anding o accina ion.
2. Analyze how CI is mobilized o manage in o ma ion
abou accina ion.
3. Assess how OH and CI a e a icula ed in he p ac ice o
c i icali y when assessing in o ma ion on accina ion.
Objec i e 1 can bee alua ed in Modules 1, 5; objec i e 2in
Modules 2, 3, 5; while objec i e 3in Modules 4, 5.
3.2 Pa icipan s
This p oposal is designed o beimplemen ed wi h Seconda y
Educa ion p e-se ice eache s wi h a scien i ic backg ound (e.g., a
deg ee in Biology, Geology, Chemis y, Physics, Pha macy …) who
a e doing a mas e ’s deg ee in science educa ion in which heal h
con o e sies a e add essed as pa o hei aining in socio-scien i ic
ins uc ion. These p e-se ice eache s do no ha e p e ious
expe ience in he class oom and his aining is he i s con ac wi h
science educa ion opics and accina ion om he OH app oach.
The design will beimplemen ed wi hin he subjec “Didac ic
Designs on Science Educa ion” du ing he nex school yea 2024–
2025. E hical conside a ions will becon empla ed du ing his p ocess
o implemen a ion and da a analysis acco ding o cu en legisla ion.
3.3 Design p inciples
Mos o he lea ning en i onmen s and designs p oposed in he
li e a u e o os e CT a e mainly ocused on he use o SSIs as a
con ex o p omo e c i ical a gumen a ion, due o hei complex and
con o e sial na u e (23, 24). SSIs ela ed o biology and en i onmen al
educa ion, such as accina ion, a e conside ed p i ileged con ex s o
os e CT de elopmen (25). These designs a e mainly based on he
CT amewo k p oposed by he Delphi s udy o Facione (26) and in
he no ion o CT p o ided by Kuhn (27) ha conside CT a dialogical
p ac ice. Acco ding o Facione CT in ol es se e al cogni i e skills,
a ec i e disposi ions and domain-speci ic knowledge. Facione’s
amewo k is equen ly used as an ope a i e ool o eache s aining
in CT (28, 29).
Al hough weag ee wi h he Facione (26) amewo k, cu en
ci izens a e exposed o la ge amoun s o in o ma ion, some o which
can cons i u e mis−/dis−/mal-in o ma ion. Thus, eache s mus
encou age he skills o manage all his in o ma ion o make decisions
and ake ac ions, e en when he e is low domain-speci ic knowledge
o a ce ain SSI. This leads o he need o os e CI along wi h CT in
science educa ion (5, 22, 30). This design p o ides ools o pu in
p ac ice CI in science educa ion (Modules 2, 3).
Osbo ne and Pimen el (31) p opose a wo k low abou how
scien i ic claims and in o ma ion should be e alua ed. This
amewo k is used as a amewo k o ou design (Figu e 1)
(Modules 2, 3).
Ou app oach is ocused on CI as pa o CT o iden i y he sou ce
o in o ma ion and assess i s c edibili y as an essen ial dimension o
CT in cu en socie ies. These a e essen ial skills o imp o ing
decision-making, and p omo ing c i icali y (Module 4).
De eloping an in eg al ision o accina ion is a aluable ool o
c i icali y and accine p omo ion. Wea gue ha OH is an app oach
ha allows o aise awa eness abou di e en ac o s ha a ec
accina ion and p o ides a be e unde s anding o accine hesi ancy.
This deepe unde s anding o he cu en si ua ion o e s he chance
o ackle he p oblem o accine hesi ancy in a mo e in eg al way.
Mo eo e , i allows us o use di e en skills o CT mo e e icien ly
when e alua ing he p oblem. Fo ins ance, an OH app oach will
acili a e he applica ion o CI when assessing in o ma ion ega ding
accines. This s ep is essen ial o decision-making and aking ac ion,
when c i icali y becomes essen ial. The OH app oach is included in
Module 1.
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4 Resul s: an ins uc ional design o
c i icali y on accina ion om he OH
app oach
Ou design is a 10-h aining cou se o p e-se ice/in-se ice
Seconda y Educa ion science eache s. The ins uc ion is o ganized in 5
modules (1.5 h/module). I is a lexible ins uc ion ha can beadap ed o
he ini ial le el o he pa icipan s, and be scheduled acco ding o
pa icipan s’ a ailabili y. I seeks o p o ide e icien ways o in oduce
OH and C i icali y o p omo e accina ion in science lessons. Table1
p o ides an o e iew o he design and highligh s he main dimension
(OH, CI, o C i icali y) add essed in each module. The OH app oach
unde lies he whole design, as he global pe spec i e o he p oblem
p o ided by OH is necessa y o p ope ly pu in p ac ice CI and C i icali y.
The wo k low o his design was elabo a ed conside ing he main
abili ies needed in di e en momen s o in o ma ion managemen
FIGURE1
Reasoning wo k low o decision-making du ing accine in o ma ion e alua ion [based on Osbo ne and Pimen el (31)].
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ha lead o decision-making and aking ac ions. Fi s ly, de eloping a
wide and complex unde s anding o he p oblem is desi able. This is
add essed in Module 1 whe e OH can bea bene icial app oach o his
pu pose. A e wa ds, his mul i-s ep p ocess in ol es managing
in o ma ion e icien ly whe e CI plays a cen al ole and ha is ackled
in Modules 2 and 3. The p e ious s eps would lead o decision-making
and de eloping ac ions o ace he p oblem, when C i icali y
gains p ominence.
4.1 Module 1: how can we aise awa eness
on accina ion?
This module includes a b ains o ming and one ac i i y o help
pa icipan s unde s and he ole o accines in public heal h and he
consequences o low- accina ion co e age. I s main goal is o
in oduce he OH app oach in connec ion wi h he p oblem o
accina ion. Also, a en ion is on he way eache s can aise
awa eness among he s uden s abou he social p oblem o low
accina ion co e age. Fo his, he concep o OH is in oduced
and explained.
4.1.1 Ac i i y – b ains o ming
P e-se ice eache s a e asked o exp ess hei own opinion abou
heal h and accina ion. This will allow us o in oduce he opic and
also o iden i y hei ini ial iew. The ollowing ques ions can beused
o guide his ac i i y:
• Wha is heal h? How would you de ine i using you own
wo ds?
• Do you hink ha human heal h can bea ec ed by en i onmen al
and animal ac o s?
• I so, how do hey a ec human heal h?
4.1.2 Ac i i y – using he OH app oach o
assessing accina ion
Teache s a e asked o apply he OH app oach o he p oblem o
unde accina ion and o ep esen hei iew in a diag am. Wesugges
p esen ing he p oblem o in ec ious diseases and unde accina ion
as a global heal h p oblem by using he OH app oach. This app oach
pu s in o pe spec i e he complexi y o new in ec ious-disease
eme gence, and he p e en able-disease ou b eaks. This con ex allows
o highligh he ele ance o accina ion as a communi y ool o
p e en in ec ious diseases. A guiding ques ion can be used o
in oduce his issue.
Figu e2 is an example o how OH p o ides a global iew abou
in ec ious diseases and he ole o accina ion. As showed in Figu e2
accina ion plays an impo an ole in he sys em o in e ac ions.
Vaccina ing domes ic animals and human communi ies can
po en ially limi he isk o eme gence o new in ec ious diseases, and
specially p o ec s he popula ion om se e e diseases when in ec ion
occu s. Hence, i mainly ac s in he Animal-Human in e ac ions.
Addi ionally, human ac o s (Figu e2, pu ple bubble) can also
bemodi ied o inc ease accina ion. A his le el, accine educa ion
will aise awa eness abou he impo ance o a high accine co e age
as a communi y “shield” agains in ec ious diseases.
Secondly, a g oup discussion will bepe o med. Pa icipan s a e
asked o explain hei OH app oach o he es o he g oup. All
models a e discussed among he whole g oup o en ich he lea ning.
Bo h ac i i ies show he u ili y o he OH app oach, and p o ide
pa icipan s wi h ways o in oduce he OH in hei lessons.
A he end o his module i would beexpec ed ha eache s
imp o e hei abili y o:
• Fos e OH ega ding accina ion among s uden s.
• Raise awa eness abou he isks o low accina ion a es
among s uden s.
TABLE1 O e iew o he cou se o seconda y educa ion eache ins uc ion “How can Ip omo e accina ion om a sys emic, c i ical, and ac i e
pe spec i e?”
Module Topic/dimension Objec i e CI/OH/c i icali y Du a ion (min)
1How can we aise awa eness abou accina ion in science
class ooms?
P omo ing an in eg al ision o
global isks o
unde accina ion.
OH 90
2How can Ihelp s uden s o a oid
accine allacies?
(I): Looking o e idence P o iding ools o
in o ma ion managemen and
o a oid o e -in o ma ion in
ela ion o accines.
CI
45
(II): Con as ing
in o ma ion 45
3 How can I aise us in accines?
De eloping s a egies o each
abou he ele ance o
scien i ic knowledge and he
Na u e o Science o inc ease
us in accines.
CI 90
4 Wha can wedo o p ese e public heal h?
Lea ning how o o ien
eaching owa d c i ical ac ion
ega ding accina ion.
C i icali y 90
5 P opose a new design using OH app oach
Applying he lea n du ing he
ins uc ion o you own
class oom and con ex .
OH
CI
C i icali y
90
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• Emphasize he impo ance o accina ion o main aining a good
global heal h s a us among s uden s.
4.2 Module 2: how can accine allacies
bep e en ed among s uden s? (I) (II)
A e lea ning abou he po en ial o OH o p omo e a sys emic
unde s anding o accina ion, pa icipan s a e in oduced in o he
second module, which is ocused on p omo ing CI o a oid
allacies and educe accine hesi ancy when looking o
in o ma ion. This module consis s o wo sec ions ha co espond
o he i s and second s eps o he me hodological app oach
(Figu e1).
To de elop an opinion abou accines, s uden s should look o
in o ma ion abou hei u ili y. Howe e , some pieces o in o ma ion
can bemisleading, especially in he pos - u h e a. Thus, eache s
should p o ide hei s uden s wi h ools o manage all he in o ma ion
hey a e exposed o, and CI plays a cen al ole a his s age. Thus, he
wo sec ions o his module a e ocused on di e en s eps o pu ing
CI du ing he analysis o a piece o in o ma ion.
4.2.1 Pa (I): looking o e idence
This sec ion includes an ac i i y ocused on assessing how o
ackle he i s ques ion o he me hodological app oach: “Is he sou ce
o in o ma ion c edible?”
A sho o e iew o he p ocess o e alua ing accine- ela ed
in o ma ion (Figu e1) is pe o med as his is a use ul way o each
s uden s how o manage accine o e -in o ma ion and misleading
in o ma ion. Fo a be e unde s anding o his wo k low, illus a i e
examples ha pa icipan s mus sol e a e p o ided.
4.2.1.1 Ac i i y – looking o e idence
Di e en pieces o in o ma ion ob ained om di e en sou ces
and/o sel -elabo a ed (i.e., news, commen s on he web, ideos,
scien i ic pape s…) a e p o ided. To answe he ques ion “Is he
sou ce o in o ma ion c edible?” guiding ques ions a e also p o ided
(Figu e3).
FIGURE2
Illus a i e example o he ele ance o accina ion o p e en he eme gence o in ec ious diseases om he One Heal h app oach.
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No e ha his is adap ed o he le el o expe ise expec ed om
he pa icipan s (p e-se ice/in-se ice Seconda y Educa ion eache s
wi h a biology/na u e sciences/biomedical deg ee, o simila ).
Howe e , guiding ques ions can beapplied o any piece o accine
in o ma ion and o di e en le els o expe ise o s uden s (Figu e3),
and so does he es o he ollowing ac i i ies.
A he end o his sec ion, i would be expec ed eache s o
imp o e hei abili y o:
• Help s uden s o look o e idence when e alua ing a piece o
in o ma ion o a oid accine allacies.
4.2.2 Pa (II): con as ing in o ma ion
Pa icipan s will assess he second ques ion included in he design
(Figu e1) “Does he sou ce ha e he expe ise in accines o suppo
i s claims?.” This sec ion includes an ac i i y ocused on he expe ise
o he sou ce/au ho o a piece o in o ma ion o accep / ejec a sou ce
as us able.
4.2.2.1 Ac i i y – is expe ise a c i e ion o c edibili y?
Di e en sou ces o in o ma ion a e p o ided o hei analysis.
Pa icipan s a e equi ed o look o addi ional in o ma ion ela ed o
he sou ce/au ho o each piece o in o ma ion. The addi ional
FIGURE3
Rep esen a i e example o he ma e ial p o ided o ac i i y 2 “Looking o e idence.” Panel 1 includes he piece o in o ma ion (in his case, a YouTube
ideo). Panel 2 co esponds o he guiding ques ions used o assess he c edibili y o he in o ma ion sou ce. Panel 3 ep esen s he concluding
ema ks ha should beex ac ed a e analyzing he ques ions o panel 2. Panel 1′ is an example o a piece o in o ma ion adap ed o de eloping his
ac i i y wi h Seconda y Educa ion s uden s (12–16 yea s old) in science lessons; sc eensho image om h ps://www.you ube.com/
wa ch? =zBkVCpbNnkU, © Ku zgesag – In a Nu shell, used wi h pe mission.
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F on ie s in Public Heal h 02 on ie sin.o g
Addi ionally, he socie al pe spec i e needs o be add essed. Besides he
a o emen ioned hemes, gene al counselling should ocus on mispe cep ions
o accine sa e y and he ole o misin o ma ion which a e also impo an in
he non-p egnan popula ion. This s udy unde lines he impo ance o including
p egnan indi iduals in esea ch p og ams o ob ain speci ic in o ma ion
a ge ed o hei needs.
KEYWORDS
p egnancy, p egnan indi iduals, COVID-19, accine hesi ancy, SARS-CoV-2
1 In oduc ion
The COVID-19 pandemic has an eno mous global impac , and
he e o e is di e en om o he ecen in ec ious disease ou b eaks
(1–3). Disease bu den, social isola ion and dis ancing, loss o wo k,
men al heal h p oblems and economic implica ions we e unique in
in ensi y, ab up ness and se e i y and many o hese s ill con inue o
ha e an e ec on socie y.
Vaccines agains he i us ha causes COVID-19, se e e acu e
espi a o y synd ome co ona i us 2 (SARS-CoV-2), we e de eloped in a
e y as and no el manne , enabling p o ec ion agains he sequelae o an
in ec ion wi h he i us, especially he mRNA accines. Mo e han 70%
o he gene al popula ion accep ed he accine (4). Du ing he pandemic,
p egnan indi iduals we e mo e hesi an o ecei e a accina ion
compa ed o he gene al popula ion (5–8). This is pa icula ly impo an ,
since p egnan indi iduals we e mo e ulne able o complica ions om
COVID-19. Al hough se e e COVID-19 is uncommon, compa ed o
non-p egnan indi iduals, p egnan indi iduals showed highe a es o
in ensi e ca e uni (ICU) admission, in asi e en ila ion, ex aco po eal
memb ane oxygena ion (ECMO) and highe mo ali y a es (9).
Fu he mo e, p egnan indi iduals wi h se e e COVID-19 ha e highe
a es o ia ogenic p e e m bi h, leading o highe a es o neona al
in ensi e ca e uni (NICU) admissions (10). When compa ing p egnan
indi iduals wi h COVID-19 o p egnan indi iduals wi hou COVID-19,
se e e neona al complica ions a e highe in p egnan indi iduals wi h
COVID-19 (11). Faja do-Ma inez e al. ound neu ode elopmen al delay
in child en age 5–30 mon hs who we e exposed o ma e nal Sa s-CoV-2
in u e o (12).
Ini ially, in 2020, p egnan indi iduals we e excluded om phase
2 and 3 COVID-19 accine ials, due o sa e y egula ions (13).
Howe e , in se e al coun ies, e.g., in he USA, p egnan indi iduals
we e able o ecei e he accine (14). As a esul , da a on he sa e y and
e ec i i y o he accine became apidly a ailable. These da a and da a
om indi iduals who inad e en ly became p egnan du ing he
COVID-19 accine clinical ials showed simila immunogenici y o
p egnan indi iduals compa ed o non-p egnan indi iduals (15) and
no speci ic isks, including side e ec s o ad e se bi h ou comes (16,
17). This esul ed, a i s , in an ad ice o p egnan indi iduals wi h
unde lying medical heal h condi ions o an occupa ion wi h high isk
o con ac wi h SARS-CoV-2, o ge accina ed (18). When mo e da a
became a ailable, he (in e na ional) ad ice changed om accina ion
o his selec ion o p egnan indi iduals o accina ion o all p egnan
indi iduals (19). In Ne he lands, p egnan indi iduals we e ad ised o
ecei e a mRNA accine (P ize BioNTech BNT162b2 and Mode na
mRNA-1273). Addi ionally la e da a showed ma e nal COVID-19
accina ion was associa ed wi h lowe isk o COVID-19 ela ed
hospi aliza ion in in an s <6 mon hs o age (20). Howe e , p egnan
indi iduals emained hesi an o ecei e a COVID-19 accine (21);
wi h an es ima ed accep ance pe cen age o 49% wo ldwide (4, 22).
Vaccine hesi ancy has been de ined as “a delay o e usal o
accina ion despi e he a ailabili y.” The e a e se e al de e minan s ha
in luence accine hesi ancy which a y ac oss ime, be ween diseases,
accines and communi ies (23). To in es iga e wha de e minan s a e o
in luence, wo commonly used models a e a ailable o explain accine
hesi ancy. The i s model is he 3 C’s model, comp ising o complacency,
con enience and con idence (23). Wi hin his model, complacency is he
pe cei ed no ion ha he isk o accine-p e en able disease is low and
he e o e accina ion is no a necessa y p e en i e measu e. Con enience
comp ehends ac o s such as geog aphical accessibili y, a o dabili y,
physical a ailabili y and he abili y o unde s and in e ms o heal h
li e acy. Con idence is de ined as us in he sa e y and e ec i eness o
accines and he sys em ha deli e s hem. This includes he compe ence
o heal h ca e wo ke s p o iding he accine. The Heal h Belie e Model
(HBM) is ano he concep ha is used o explo e and explain he a ionale
behind accine hesi ancy, as i is a widely used o p edic heal h beha iou
(24). The HBM elies on sel -e icacy in explaining heal h beha iou and
pe cei ed suscep ibili y, se e i y, bene i s, and ba ie s. The HBM is based
on he hypo hesis ha he esponse o a heal h h ea is de e mined by a
pe son’s pe cei ed se e i y o he h ea and suscep ibili y o he h ea .
Engaging in heal h p o ec i e beha iou is de e mined by he es ima ed
bene i s o he p o ec i e beha iou and po en ial ba ie s agains
he beha iou .
P edic o s o COVID-19 accine accep ance in p egnan
indi iduals among di e en s udies include: ad anced ma e nal age,
occupa ional s a us (employed indi iduals we e mo e likely o ecei e
accina ion), highe educa ional le el, whi e ace, ha ing a p e ious
in luenza accina ion, hi d imes e o p egnancy, como bidi ies,
knowledge abou COVID-19 (25–28). Du ing he COVID-19
pandemic, an addi ional and unadd essed issue possibly con ibu ing
o accine hesi ancy in p egnan indi iduals was physician hesi ancy
o ecommend he accine o p egnan indi iduals (29).
Due o he unique challenges and changes du ing he COVID-19
pandemic, wehypo hesize ha di e en and pe haps unique ac o s
can beiden i ied in he decision-making p ocess ega ding accina ion
agains COVID-19 du ing p egnancy. This knowledge is impo an in
he pe spec i e o upcoming diseases and necessi y o newly de eloped
accines (30, 31).
The e o e, he aim o his quali a i e s udy is o explo e ba ie s
and acili a o s o indi iduals in hei decision ega ding accina ion
agains a new i us, COVID-19, du ing p egnancy. The esul s o his
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F on ie s in Public Heal h 03 on ie sin.o g
s udy help o p o ide insigh in o which speci ic in o ma ion will help
p egnan indi iduals o make an in o med decision abou using newly
de eloped accines and acili a es implemen a ion o new accines in
he nea u u e du ing p egnancy.
2 Ma e ials and me hods
2.1 Design
We conduc ed a quali a i e s udy o li ed expe iences o p egnan
indi iduals ega ding he decision-making p ocess o accina ion
agains COVID-19. A quali a i e design was chosen as weaimed o
gain a comp ehensi e unde s anding o he ba ie s and acili a o s
ha p egnan indi iduals encoun e in he decision-making p ocess.
Semi-s uc u ed in e iews we e conduc ed ha ook a na a i e
app oach. Wehypo hesized ha p egnan indi iduals pe spec i es on
accina ion a e uelled by hei pe sonal expe iences and opinions, bu
also in e ac wi h he socie y su ounding hem (32). A hema ic
analysis was chosen o analyse he da a, as his me hodology i s
wi hin he cons uc ionis pa adigm and holds space o an inqui y in
he eali y o pa icipan s.
2.2 Resea ch eam
A mul idisciplina y esea ch eam ensu ed a ie y in pe spec i es.
The esea ch eam included h ee gynaecologis s, a psychia is , a
gynaecologis in aining and wo PhD candida es in he ield o
p egnancy, men al heal h and COVID-19.
2.3 Se ing and ec ui men o pa icipan s
P egnan indi iduals who ecei ed p ena al ca e in a e ia y ca e
cen e, Ams e dam Uni e si y Medical Cen e –loca ion VUmc
(Ams e dam UMC – VUmc) and low- isk p egnan indi iduals in
midwi e y p ac ices in he Ams e dam a ea we e asked o pa icipa e
in he s udy. Pu posi e sampling was conduc ed o ob ain a sample o
p egnan indi iduals om di e se backg ounds including a ia ions in
ma e nal age, pa i y, coun y o bi h, educa ional le el and accina ion
s a us. P egnan indi iduals ≥18 yea s and wi h su icien knowledge
o he Du ch o English language we e ound eligible o pa icipa e in
he s udy. Eligible indi iduals we e ini ially app oached by hei heal h
ca e p o essional and subsequen ly by he i s au ho (SJMZ), o
bein o med abou he s udy. Pa icipan s ecei ed an in o ma ion
le e , including an in o med consen o m. A e in o med consen
was ob ained, an in e iew da e was scheduled. Pa icipan s could
wi hd aw consen a any ime. Pa icipan s we e allowed o b ing a
suppo pe son o he in e iew. In e iews we e scheduled un il no
new hemes eme ged om he da a.
2.4 Da a collec ion
All da a we e collec ed be ween Oc obe 2021 and Janua y 2022
(see Figu e1, imeline o lockdowns, accina ion a ailabili y and
s udy pe iod).
Du ing a ou -mon h pe iod, semi-s uc u ed in e iews ook place
by phone, ideo call o onsi e a he Ams e dam UMC, depending on he
p e e ence o he pa icipan . Onsi e in e iews we e conduc ed in a
p i a e consul a ion oom wi hin he hospi al’s ou pa ien clinic. The
space was u nished wi h a desk, wo chai s, and a small side able wi h
in o ma ional pamphle s. This loca ion was chosen o c ea e a secu e,
calm en i onmen o he pa icipan . Despi e he clinical se ing, e o s
we e made o make he pa icipan eel com o able, wi h he in e iewe
o e ing d inks and explaining he pu pose o he in e iew clea ly a he
ou se . The choice o a hospi al se ing was in ended and in consul a ion
wi h he pa icipan o make i con enien o he pa icipan , who was
al eady isi ing he clinic o an appoin men . In e iews las ed be ween
25 and 45 min and we e conduc ed by he i s au ho (SJMZ). All
in e iews we e audio- eco ded.
The sel -de eloped in e iew guide (see Appendix 1) included a
sho lis o backg ound and gene al ques ions. To add ess he
hough s and ideas ega ding accina ion and in pa icula COVID-19
accina ion, he in e iew s a ed explo ing subjec s such as; gene al
ideas on accina ion, p io accina ions, hough s abou COVID-19in
gene al, expe iences wi h COVID-19, sou ces o in o ma ion on
COVID-19, opinions o heal hca e p o ide s, ela i es and iends on
he subjec o COVID-19 accina ion. Depending on he answe s,
mo e in-dep h ques ions we e asked o elabo a e on he
p e ious answe s.
The s udy design and epo ing adhe ed o Consolida ed C i e ia
o Repo ing Quali a i e esea ch (COREQ).
FIGURE1
Timeline o lockdowns, s a o accina ion and s udy pe iod in Ne he lands.
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TABLE1 Backg ound cha ac e is ics o he pa icipan s.
Pa icipan s (N= 9)
Age (mean, SD) 34.8 (3.8)
Coun y o bi h
Belgium 1
Bulga ia 1
India 1
Mo occo 1
Ne he lands 4
Su iname 1
Educa ional le el
Seconda y oca ional educa ion 3
Highe p o essional educa ion 3
Uni e si y educa ion 3
Ma i al s a us
Single 0
Li ing apa oge he 1
Li ing oge he 5
Ma ied 3
P e ious ea men o psychological dis ess
Yes 4
No 4
Unknown 1
Pa i y
P imipa a 2
Mul ipa a 7
Ges a ional age in weeks (mean,
SD)
32.4 (6.2)
Ges a ion
Fi s imes e 0
Second imes e 3
Thi d imes e 6
P ena al ca e
Hospi al 8
Midwi e y p ac ice 1
P e ious COVID-19 (sel - epo ed)
Yes 6
No 2
Unknown 1
Vaccina ed agains COVID-19
Yes 5
No 4
The bold alues s a e he backg ound cha ac e is ics.
2.5 Da a-analysis
In e iews we e eco ded and ansc ibed ad e ba im, ollowed
by coding acco ding o he p inciples o hema ic analysis (33) using
he quali a i e analysis so wa e MAX QDA. The analysis included a
p ocess o amilia izing wi h he da a (by eading and e eading
ansc ip s), coding and in e p e a ion. Ini ially, open coding o all
ansc ip s was pe o med by he i s au ho (SJMZ). To en ich he
a ie y o codes and o complemen each o he ’s coding, wo
in e iews we e also coded by he second au ho (ALR) and h ee by
he hi d au ho (NNS). Subsequen ly, in e p e i e coding was
conduc ed by he esea ch eam in a g oup mee ing o e ing di e se
pe spec i es o enhance eliabili y. Themes we e cons uc ed om he
selec i e codes as weex ac ed pa e ns o sha ed meaning om he
da a. The ansc ip s and indings we e no e u ned o he pa icipan s
o membe checking.
2.6 E hical conside a ions
The Medical E hics Re iew Commi ee o VU Uni e si y Medical
Cen e examined he s udy p o ocol (2021.0245). O icial app o al
was no equi ed. The p o ocol was in acco dance wi h Du ch
p i acy egula ions.
3 Resul s
A o al o nine p egnan indi iduals pa icipa ed in he s udy.
Du ing he ec ui men pe iod o he s udy, eigh indi iduals declined
o pa icipa e in he s udy, six o hese indi iduals we e no
accina ed. Thei main eason o no pa icipa ing was unwillingness
o discuss he opic. The o he wo indi iduals we e accina ed and
did no gi e a pa icula eason o no wan ing o pa icipa e in he
s udy. Ou o he nine in e iews, one in e iew was conduc ed
in English.
Pa icipan cha ac e is ics a e shown in Table1. Ma e nal age
anged om 28 o 40 yea s. Mos o he pa icipan s we e mul ipa ous
and had ecei ed ca e a he Ams e dam UMC. None o he
in e iewed indi iduals we e in hei i s imes e , ges a ion anged
om 22 o 39 weeks.
A e analyses, h ee main hemes, ela ed o decision-making
ega ding accina ion in p egnancy, we e iden i ied: (1) Heal h
consequences, (2) Ambigui y o in o ma ion, and (3) Socie al
mo i a ion. Themes and sub hemes a e desc ibed in Table 2.
T ansla ed quo es suppo he hemes. In addi ion, Table3 shows he
hemes wi h he main explana ions in accina ed e sus un accina ed
p egnan women.
3.1 Heal h consequences
Pa icipan s pa icula ly exp essed he impo ance o heal h
o hei unbo n child. The unknown consequences o accina ion
o hei o sp ing we e a main conce n. This led o insecu i ies
ega ding he sa e y o accina ion e sus he impo ance o
accina ion, and also o insecu i y e sus con idence in hei
own heal h.
3.1.1 Insecu i y e sus con idence in impo ance
o accina ion
The majo i y o he pa icipan s ecalled ha p io o hei
p egnancy hey we e mo e open o eceip o a accine. Howe e ,
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F on ie s in Public Heal h 05 on ie sin.o g
pa icipan s pe cei ed p egnancy o ha e a “special s a us”. This s a us
conce ns esponsibili y o he sa e y o he unbo n child esul ing in
being ex a ca e ul wi h die a y es ic ions and aking medica ion
and, in addi ion, eluc ance owa ds accina ion.
“Yes, 100%. I Ihad no been p egnan , Iwould ha e aken i
immedia ely” (P2).
“Especially because du ing p egnancy you y eally ha d and do
you bes no o ea ce ain oods, ake a lo o i amins, you ake
all hese hings in o conside a ion, and hen you ake a accine o
which youdo no know he long- e m e ec s, his causes mixed
eelings” (P1).
3.1.2 Insecu i y e sus con idence in own heal h
Pe cei ed physical heal h is an impo an heme bu di e s among
pa icipan s. Some pa icipan s pe cei ed hei heal h as good and
he e o e we e eluc an o choose accina ion.
“Because basically, Isee mysel as a heal hy pe son” (P9).
In e es ingly, ano he pa icipan desc ibed he opposi e.
Explaining ha he physical disabili y she al eady el om being
(hea ily) p egnan made he unsu e o wha would happen i she
would ge a COVID-19 in ec ion as well.
“Because now I eally no iced ha my b ea hing is high and
shallow, and s anding up, Iimmedia ely el dizzy and ou o
b ea h, and I el sho ness o b ea h a nigh when Iwoke up. I
his is how I eel jus because o he p egnancy, hen Ido no
hink i will beokay i Iha e ha (COVID-19) on op” (P4).
O he pa icipan s desc ibed ha ing expe ienced COVID-19in
he pas wi hou se e e symp oms being one o he easons no he
choose accina ion. As desc ibed abo e, ulne abili y o heal h
du ing p egnancy was an impo an heme. Whe he o no ha
ulne abili y was a eason o accina ion, di e ed
be ween pa icipan s.
One pa icipan desc ibed ha she el like he immune sys em
was weake and she was no su e i she wan ed o ecei e a second
accina ion du ing p egnancy, due o ea o eeling ill om he side
e ec s o accina ion ins ead o om COVID-19 in ec ion.
“Because I eel ha my immuni y is now a bi lowe . Iama aid
ha hose side e ec s om a possible second dose a e mo e
in ense, and ha Iwill ge sick o ha ” (P4).
3.1.3 Consequences o o sp ing
One o he i ems ha was epea edly men ioned du ing he
in e iews was no being able o know i he e would beany ad e se
long- e m e ec s o accina ion, in pa icula o hei o sp ing. Some
pa icipan s speci ically exp essed a ea o bi h de ec s and long-
e m e ec s ega ding o example in e ili y o a en ion diso de s in
hei o sp ing.
“[…]I was only allowed an mRNA accina ion, bu he long- e m
e ec s a e jus no known and o cou se you ha e hose
die hyls ilbes e ol (DES) child en and he So enon and youha e
mo e hings ha happened in he pas wi h medica ion ha
u ned ou no o besuch a good idea in he longe e m, Ijus did
no da e o ake his” (P7).
“Yes, I ind ha ha d o say. […]. I ind i di icul i my child u ns
30 and wan s o ha e child en o i s own and hen i u ns ou heo
she is less e ile. Ido no belie e my child will come ou wi h 5
a ms, o ha so o hing, bu maybe he o she will ha e an
a en ion de ici diso de o some hing like ha , and ha ha could
belinked o he accine. Iwould ind ha e y di icul ” (P1).
3.1.4 Consequences o illness
Ano he ac o ha in luenced decision-making ega ding
COVID-19 accina ion a e pe sonal expe iences. Some pa icipan s
desc ibed how hey el when hey had COVID-19.
“No, Ijus had a li le muscle ache, jus like when Iha e lu. O he
han ha , Iha e had no complain s” (P9).
TABLE2 O e iew o hemes and sub hemes.
Themes Sub hemes
Heal h consequences • Insecu i y e sus con inced o impo ance
o accina ion
• Insecu i y e sus con idence in own heal h
• Consequences o o sp ing
• Consequences o illness
Ambigui y o
in o ma ion
• In o ma ion p o ision
• T us e sus scep icism
Socie al mo i a ion • Al uism
• Ex e nal mo i a ion/go e nmen ules and es ic ions
TABLE3 Main hemes wi h associa ed ac o s in accina ed e sus un accina ed women.
Vaccina ed p egnan indi iduals (n= 5) Un accina ed p egnan indi iduals (n= 4)
Heal h consequences ▪ Insecu i y ega ding own heal h du ing p egnancy and
addi ional isks o COVID-19 in ec ion
▪ Unknown consequences o o sp ing
Ambigui y o
in o ma ion
▪ T us in in o ma ion om heal h ca e p o ide s/ amily ▪ Scep ical abou sca ce esea ch (a he ime)
▪ Ambiguous in o ma ion p o ision, wi h ad ise changing om no accina ing
p egnan indi iduals o ou inely accina ing p egnan indi iduals
Socie al mo i a ion ▪ Unable o li e a “no mal” daily li e
▪ No being able o a el wi hou accina ion
▪ Feeling de ensi e, due o nega i e commen s om socie y bu his s eng hened
hei own decision
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“Well i was no pleasan , i was ha d, bu luckily Iwas a home.
Idid no ha e o go o he hospi al. Bu Ihad o cough a lo and
Iha e ne e been his sick in my li e. Le me pu i his way, i was
much mo e han a lu” (P5).
O he pa icipan s desc ibed ha ing amily o iends who had
COVID-19 wi hou any se e e symp oms o hospi al admission. One
pa icipan sha ed ha she had los a amily membe due o
complica ions o a COVID-19 in ec ion and ano he pa icipan
desc ibed how someone she knew had deli e ed a baby while she had
a COVID-19 in ec ion and he a e ma h o he in ec ion.
“She eally did no ha e enough oxygen o push and she was
be ween li e and dea h. A e she ga e bi h, she also walked
h ough he house wi h an oxygen ank and a baby on he o he
a m o mon hs” (P7).
3.2 Ambigui y o in o ma ion
A second heme ocuses on he ela ion be ween in o ma ion
p o ision and decision-making ega ding accina ion. In gene al,
pa icipan s ound i impo an ha in o ma ion is p o ided in a
clea and concise way. In o ma ion was a ailable om heal h ca e
p o ide s and h ough di e en pla o ms, such as ele ision,
newspape s, online and social media. Pa icipan s we e ha ing
di icul ies o de e mine which in o ma ion was eliable.
3.2.1 In o ma ion p o ision
Se e al pa icipan s ha e poin ed ou he di icul y o he
accina ion ad ice changing o e ime om no ( ou inely)
accina ing p egnan women due o lack o da a abou he sa e y
du ing p egnancy, o he ad ice o accina ing all p egnan women.
“The con e sa ions we e o e all good, he unny hing was, ha
people who go p egnan a he same ime as me, we e also ad ised
no o ge accina ed […]. Bu a e he go e nmen ad ised
e e ybody o ge accina ed, people who ha e go en p egnan
since ollow ha ad ice” (P1).
In addi ion, pa icipan s sea ched o in o ma ion online, anging
om scien i ic websi es o news websi es and o na ional accina ion
ad iso y boa ds. Mul iple pa icipan s exp essed ha in o ma ion on
social media did no in luence hei decision, because hey did no
ake his in o ma ion pla o m se iously.
“Th ough he in e ne , bu I y o seek scien i ic a icles, no
Wikipedia o a p egnan pe son’s pe sonal blog. Ialso looked o
simple hings such as: how long has he accine been used, how
many yea s has i been es ed, in which coun ies, all hose so s
o hings” (P1).
3.2.2 T us e sus scep icism
Despi e he ac ha pa icipan s el he decision ega ding
accina ion was a decision hey had o make on hei own, some
pa icipan s we e in luenced by opinions om people a ound hem,
including ela i es and heal h ca e p o essionals. One pa icipan
poin ed ou ha he midwi e ad ised agains accina ion. Ano he
pa icipan wi h mul iple ela i es wo king in he medical ield,
us ed hei opinion when hey explained ha accina ion is
ecommended based on conduc ed esea ch.
“I discussed i wi h my amily, because hey a e all doc o s. Two GP’s
and a neu ologis and hey said yes, go ahead, i ’s sa e. Weha e
al eady seen a lo o s udies, Iwould de ini ely ecommend i ” (P4).
Ano he pa icipan desc ibed how he combina ion o esea ch,
media, he pa ne and his colleagues made he change he mind
ega ding accina ion.
“Yes, su e, because a i s Idid no wan i […]. Un il a one
poin , he news epo ed ha p egnan women we e a high isk,
especially owa ds he end o he las imes e . You belly is
bigge and youha e less lung capaci y, so he chance is highe
ha you end up in he ICU. […] I hough : oh, Iwill soon
behea ily p egnan in he win e , du ing he cold and lu season.
[…] Colleagues o my husband ha a e doc o s also said: all
p egnan women weknow, including doc o s, had he accina ion
hemsel es. Then I hough : Ijus ha e no choice, accina ion is
p obably sa e han I hink. The isk o he longe e m does no
ou weigh he ac ual isk o me and he child ha may ha e o
bedeli e ed ea ly i Ige COVID” (P2).
One pa icipan was scep ical abou he esea ch on which he ad ice
o ou inely accina e all p egnan women was based on. Ano he
pa icipan explained ha she became mo e doub ul when she came
ac oss links on websi es ha asked he o pa icipa e in esea ch
ega ding COVID-19 accina ion du ing p egnancy. To he i was a
con i ma ion ha accina ion o COVID-19 was s ill subjec o esea ch.
“A i s i is discou aged and hen s ongly ecommended a e a
s udy in Ame ica […]” (P5).
“Especially when Iwas on he websi e o he Na ional Ins i u e
o Public Heal h and he En i onmen (RIVM), links o
p egnan women kep popping up: pa icipa e in a s udy so
wecan see wha he accine does, and Iunde s and 100%, I ully
unde s and ha i is some hing e y no mal ha his is being
in es iga ed. Only wi h me pe sonally, Ido no know, i made
me doub e en mo e, ha I hough : oh yes, see, hey ac ually
s ill ha e o in es iga e his” (P2).
3.3 Socie al mo i a ion
The hi d heme ela es o socie al mo i a ion and in luences o
he decision-making p ocess ega ding COVID-19 accina ion. Mos
o he pa icipan s spoke abou di e en ways in which COVID-19
in luenced socie y. Pa icipan s also epo ed di e en ways in which
socie y in luenced he decision-making p ocess ega ding
accina ion. Fo some pa icipan s al uism played a ole in he
decision o ecei e accina ion agains COVID-19, o o he
pa icipan s ex e nal mo i a ion due o addi ional ules and
es ic ions o people who we e no accina ed made hem decide o
ge he accina ion.
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3.3.1 Al uism
Some pa icipan s el an obliga ion o conside he consequences
o he whole socie y, in pa icula ulne able people and he e o e
decided o ecei e accina ion.
“[…] Iha e no had he eeling ha Iha e o p o ec mysel ha
much, bu […] Ijus hink i is impo an ha as many people as
possible ge accina ed in o de o p e en his and Iwan ed o
con ibu e o ha mysel , so ha has been he eason ha Ijus
had o ge accina ed” (P8).
3.3.2 Ex e nal mo i a ion
As p e iously desc ibed, some pa icipan s ini ially did no wan o
ecei e accina ion because hey we e no pa icula ly conce ned o
hei own heal h and we e bo he ed by he unknown long- e m e ec s.
Howe e , due o he Du ch go e nmen ules, some pa icipan s
changed hei mind. Requi ing a nega i e COVID-19 es p io o
isi ing public acili ies i no accina ed was a logis ic challenge o
pa icipan s, especially wi h a newbo n. In addi ion, he isk o social
isola ion also p o ided a new eason o choose accina ion.
“I hough , i he li le one is he e, and Iamup on my ee again,
Icanno go anywhe e du ing he win e mon hs, hen Iwould eel
e y isola ed. […]. So now I ecei ed my i s accina ion wo
weeks ago and Iamgoing o ge he second one nex week and
hen Iha e a QR code once he baby is he e. This is due o he
ules ha a e in place igh now […] I el o ced, ha sounds
hea y, bu ha is kind o wha happened” (P1).
In e na ional a el es ic ions we e also a po en ial ac o
in luencing he decision. Some o he pa icipan s we e no o iginally
bo n in Ne he lands and wi hou accina ion unable o isi amily in
o he coun ies.
“Fo example Mo occo, my pa en s li e he e, so i Iwan o isi
my pa en s, I ha e o ecei e he accina ion, because i is
manda o y i youwan o go he e” (P6).
One pa icipan desc ibed how she el judged by socie y and
go e nmen o he choice no o accina e du ing p egnancy.
“My ulne abili y, so o speak, was comple ely pu aside, as i Idid
i because Iwan o bedi icul , as i Iama c azy pe son, i does no
ma e how you wan o call i , bu you a e no seen no
acknowledged ha he posi ion as a p egnan woman is di icul ,
e en aside om all he o he ac o s. I ound ha e y in ense” (P7).
4 Discussion
4.1 Main indings
In his s udy weexplo ed he ba ie s and acili a o s o p egnan
indi iduals choice and mo i a ion ega ding accina ion agains
COVID-19 du ing p egnancy in Ne he lands.
We ound h ee hemes ha cap u e he pe spec i es o p egnan
indi iduals ega ding accina ion agains COVID-19: heal h
consequences, ambigui y o in o ma ion and socie al mo i a ion.
Heal h consequences e e ed o hei own heal h, bu also he heal h
and possible consequences o hei o sp ing. Lack o long- e m da a
and he e o e unce ain y on possible ad e se long- e m e ec s o hei
o sp ing, we e a main poin o conce n. In addi ion, unambiguous
in o ma ion p o ision based on e idence, wi h ega d o why p egnan
indi iduals we e ad ised o ecei e accina ion, is an impo an opic
ha needs o beadd essed. No only o heal h ca e p o ide s, bu also
o policy make s, na ional heal h ins i u es and socie ies o ma e nal
and oe al medicine. Fu he mo e, p o ided in o ma ion should also
ma ch indi iduals speci ic ideas, eelings and pe cep ions ega ding
accina ion and in addi ion ake li e expe iences in o accoun . The
unique es ic ions esul ing om COVID-19 being a pandemic, added
socie al mo i a ion as a eason o accina ion. Wi hou accina ion
he e we e es ic ions o a eling and en e ing public places. F om he
socie al poin o iew, al uism was also impo an and esul ed in
deciding o ge accina ion o p o ec ulne able people in socie y. The
h ee main hemes, heal h consequences, ambigui y o in o ma ion and
socie al mo i a ion, indica e ha p egnan indi iduals pe spec i es o
accina ion a e shaped by pe sonal expe iences and in e ac ions wi h
he b oade socie al con ex .
4.2 In e p e a ion o indings
Li e a u e has p o ided nume ous models o explain decision-
making in heal hca e. In compa ison o he 3C model we ound ha
con idence and complacency aligned wi h he indings om ou
s udy. We ound a con idence ba ie due o sa e y conce n o he
accine and a complacency ba ie ega ding no being con inced
ha con ac ing a COVID-19 in ec ion nega i ely impac s hei li es.
Howe e , ou s udy did no show any con enience ba ie s, ins ead
we ound con enience acili a o s such as being able o a el ab oad
a e accina ion and a oiding ha ing o ake a COVID es p io o
en e ing public places.
Fu he mo e, he Heal h Belie e Model (HBM) ha is used o
explo e and explain he a ionale behind accine hesi ancy, also
p o ides simila i ies o ou indings (24, 34). The HBM is based on he
hypo hesis ha he esponse o a heal h p oblem is de e mined by a
pe sons pe cei ed se e i y o he h ea and he indi idual pe cei ed
suscep ibili y o he h ea . Bo h o hese hemes, pe cei ed se e i y
and suscep ibili y o COVID-19 we e also seen in ou s udy. Howe e ,
in addi ion o HBM wo no ewo hy conside a ions speci ic o
p egnan indi iduals we e iden i ied in ou s udy: (1) he esponsibili y
o hei unbo n child and (2) he ulne abili y o complica ions om
a COVID-19 in ec ion due o he p egnancy.
Al hough some simila i ies be ween ou indings and bo h
models a e e iden , hese models do no acknowledge he p o ound
in luence o socie y on indi iduals decision-making ega ding
accina ion. A model ha would be e i his pa o ou indings is
a concep ual amewo k o social alues in heal h p io i y se ings,
showing he p incipal o solida i y, desc ibed in a ew di e en ways,
such as; decisions which gi e p io i y o hose who a e wo s -o in
heal h e ms which is simila o al uism in ou s udy (35). In
addi ion, he Wo ld Heal h O ganiza ion S a egic Ad iso y G oup
o Expe s on Immuniza ion (SAGE) wo king g oup on accine
hesi ancy desc ibes he complex de e minan s o accine hesi ancy
in h ee ca ego ies: (1) con ex ual in luences, (2) indi idual and
g oup in luences, and (3) accine-speci ic issues (36).
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4.3 S eng hs and limi a ions
The s eng h o his s udy is he s udy design, a quali a i e
app oach wi h semi-s uc u ed in e iews and in-dep h
ques ioning, allowing o an open con e sa ion esul ing in a b oad
spec um o in o ma ion. Weincluded indi iduals wi h a ie y in
ma e nal ages, pa i y, educa ional le el, accina ion s a us, and
coun y o bi h, o gain insigh om di e en pe spec i es, and
eached sa u a ion a e nine in e iews. A eam o esea che s
om a ious backg ounds and pe spec i es used in e p e a i e
hema ic analyses.
One o he limi a ions o his s udy is ha mos pa icipan s
ecei ed ca e om an academic hospi al. This may ha e in oduced
selec ion bias, as academic hospi als p edominan ly house
complica ed o high- isk p egnancies which migh (unconsciously)
in luence he decision-making p ocess. Fu u e s udies should
pu posi ely sample low isk p egnan indi iduals wi hou a medical
o obs e ic his o y. Ano he possible limi a ion is ha , due o he
COVID-19 pandemic, some pa icipan s p e e ed o do he
in e iew by phone o ideo call, which migh ha e in luenced he
dep h and quali y o he in e iew. In addi ion, wedid no in e iew
any indi iduals in hei i s imes e o p egnancy. The i s
imes e is an impo an phase in emb yonal de elopmen and
migh he e o e p o ide o he conside a ions, like e a ogenici y,
when i comes o accina ion.
4.4 Compa ison o o he li e a u e
Ou esul s a e in line wi h a p e ious s udy om he US
showing a pa adox ega ding oe al wellbeing be ween accina ed
and un accina ed p egnan indi iduals. Whe eas un accina ed
indi iduals we e conce ned wi h he pauci y o esea ch and
po en ial impac on he de elopmen o he oe us and he e o e
did no ecei e accina ion, accina ed p egnan indi iduals chose
accina ion o ma e nal and oe al p o ec ion agains possible
COVID-19 complica ions, ha migh lead o nega i e e ec s o
he oe us (37). This is simila o ou indings, showing ha all
p egnan indi iduals hough abou consequences o he oe us,
bu his led o di e en conclusions on whe he o no o
choose accina ion.
A p e ious quali a i e s udy in Tu key has shown simila i ies,
bu also di e ences ega ding he opinions o p egnan indi iduals
abou COVID-19 accines (38). In conco dance wi h ou indings
p egnan indi iduals epo ed ha hey belie e ha accines may
help p o ec agains disease and i ecommended by heal h ca e
p o essionals his imp o es he eeling o secu i y. Howe e , in he
Tu kish s udy, indi iduals we e a aid o hemsel es and hei
babies o die om COVID-19. This is no a pa icula ea
men ioned by p egnan indi iduals in ou s udy. These di e ences
may bedue o gene al cul u al di e ences and di e ences in us
in he di e en heal h ca e sys ems.
Ano he quali a i e s udy in he Uni ed Kingdom (UK),
conduc ed be o e accines became a ailable, highligh ed ha
p egnan indi iduals pe cei ed a COVID-19 accine as iskie han
COVID-19 i sel (39). This is in line wi h ou indings showing ha
some p egnan indi iduals pe cei ed hei own heal h as excellen
and we e o e all wo ied abou he isks and unknown ad e se
long- e m e ec s o accina ion.
4.5 Fu u e ecommenda ions
I is likely ha new pandemics will a ise in he u u e, which will
also equi e adap a ion and possibly accina ion o p e en illness and
sp eading o he i us. In addi ion, he e a e mo e in ec ious diseases,
such as espi a o y syncy ial i us (RSV), o which accines a e
de eloped o adminis e du ing p egnancy (40). Howe e , in ecen
yea s us in accina ion p og ams has declined, due o doub abou
possible side e ec s and inc easing dis us o go e nmen
o ganiza ions in gene al (41).
Fu he mo e misin o ma ion h ough social media is ela i ely
new and should no beunde es ima ed (42).
This highligh s he impo ance o p o iding an open discussion o
explo e p egnan indi iduals needs ega ding accina ion, enhance
knowledge and unde s anding, and p o ide speci ic in o ma ion o
di e en g oups o p egnan indi iduals, ins ead o only p o iding
s anda d in o ma ion o all p egnan indi iduals, o educe accine
hesi ancy (Figu e2).
5 Conclusion
P egnan indi iduals a e a speci ic and impo an g oup when i
comes o accine hesi ancy. They mus weigh hei own isks and
bene i s, as well as possible isks and bene i s o hei unbo n child.
This s udy highligh ed h ee main hemes ha e lec conside a ions o
p egnan indi iduals in he decision-making p ocess abou a new
accine agains COVID-19: heal h consequences, ambigui y o
in o ma ion and socie al mo i a ion. Pe cei ed physical heal h and
in o ma ion p o ision ega ding he isk o in ec ion du ing p egnancy
and he isks and bene i s o accina ion o a p egnan indi idual and
he unbo n child a e ac o s ha need o beadd essed du ing p ena al
consul a ions discussing accina ion. The di e en ways in which
socie y in luences he decision-making is an impo an opic o heal h
ca e wo ke s and policy make s as well.
Ou indings can con ibu e o unde s and he key poin s ha need
o beadd essed du ing con e sa ions be ween heal h ca e p o ide s and
p egnan indi iduals ega ding COVID-19 accina ion, and in addi ion
can also beimpo an o u u e accina ions du ing p egnancy. This
s udy unde sco es he impo ance o including p egnan indi iduals in
esea ch p og ams ega ding accina ion, conside ing ha he e iciency
and ad e se e ec s ha e a clea impac on success ul implemen a ion.
Da a a ailabili y s a emen
The aw da a suppo ing he conclusions o his a icle will
bemade a ailable by he au ho s, wi hou undue ese a ion.
E hics s a emen
The Medical E hics Re iew Commi ee o VU Uni e si y Medical
Cen e examined he s udy p o ocol (2021.0245). O icial app o al
was no equi ed. The p o ocol was in acco dance wi h Du ch p i acy
egula ions. W i en in o med consen om he pa ien s/ pa icipan s
o pa icipa e in his s udy was ob ained in acco dance wi h he
na ional legisla ion and he ins i u ional equi emen s.
101
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F on ie s in Public Heal h 09 on ie sin.o g
Au ho con ibu ions
SZ: Da a cu a ion, Fo mal analysis, In es iga ion, Me hodology,
W i ing – o iginal d a , W i ing – e iew & edi ing. AR:
Concep ualiza ion, Da a cu a ion, Me hodology, W i ing – e iew &
edi ing, W i ing – o iginal d a . NS: Fo mal analysis, W i ing – e iew
& edi ing, W i ing – o iginal d a , Me hodology. PB:
Concep ualiza ion, Da a cu a ion, Fo mal analysis, Me hodology,
Supe ision, W i ing – e iew & edi ing, W i ing – o iginal d a . BB:
Concep ualiza ion, Da a cu a ion, Fo mal analysis, Me hodology,
Supe ision, W i ing – e iew & edi ing, W i ing – o iginal d a . EL:
Concep ualiza ion, Da a cu a ion, Me hodology, Supe ision, W i ing
– e iew & edi ing, W i ing – o iginal d a . CG: Concep ualiza ion,
Da a cu a ion, Fo mal analysis, In es iga ion, Me hodology,
Supe ision, W i ing – e iew & edi ing, W i ing – o iginal d a .
Funding
The au ho (s) decla e ha no inancial suppo was ecei ed o
he esea ch, au ho ship, and/o publica ion o his a icle.
Con lic o in e es
The au ho s decla e ha he esea ch was conduc ed in he
absence o any comme cial o inancial ela ionships ha could
becons ued as a po en ial con lic o in e es .
Publishe ’s no e
All claims exp essed in his a icle a e solely hose o he au ho s
and do no necessa ily ep esen hose o hei a ilia ed o ganiza ions,
o hose o he publishe , he edi o s and he e iewe s. Any p oduc
ha may bee alua ed in his a icle, o claim ha may bemade by i s
manu ac u e , is no gua an eed o endo sed by he publishe .
Supplemen a y ma e ial
The Supplemen a y ma e ial o his a icle can be ound online
a : h ps://www. on ie sin.o g/a icles/10.3389/ pubh.2024.1415548/
ull#supplemen a y-ma e ial
Re e ences
1. Xiong J, Lipsi z O, Nas i F, Lui LMW, Gill H, Phan L, e al. Impac o COVID-19
pandemic on men al heal h in he gene al popula ion: a sys ema ic e iew. J A ec
Diso d. (2020) 277:55–64. doi: 10.1016/j.jad.2020.08.001
2. Mish a NP, Das SS, Yada S, Khan W, A zal M, Ala i i A, e al. Global impac s o
p e- and pos -COVID-19 pandemic: ocus on socio-economic consequences. Sens In .
(2020) 1:100042. doi: 10.1016/j.sin l.2020.100042
3. Pie abissa G, Simpson SG. Psychological consequences o social isola ion du ing
COVID-19 ou b eak. F on Psychol. (2020) 11:2201. doi: 10.3389/ psyg.2020.02201
4. Sallam M. COVID-19 accine hesi ancy wo ldwide: a concise sys ema ic e iew o
accine accep ance a es. Vaccines (Basel). (2021) 9:160. doi: 10.3390/ accines9020160
5. Ci u IM, Ci u C, Go un F, Mo oc A, Go un OM, Bu lea B, e al. De e minan s o
COVID-19 accina ion hesi ancy among Romanian p egnan women. Vaccines (Basel).
(2022) 10:275. doi: 10.3390/ accines10020275
6. Hosokawa Y, Okawa S, Ho i A, Mo isaki N, Takahashi Y, Fujiwa a T, e al. The
p e alence o COVID-19 accina ion and accine hesi ancy in p egnan women: an
in e ne -based c oss-sec ional s udy in Japan. J Epidemiol. (2022) 32:188–94. doi:
10.2188/jea.JE20210458
7. Goncu Ayhan S, Oluklu D, A alay A, Menekse Bese D, Tanacan A, Mo aloglu
Tekin O, e al. COVID-19 accine accep ance in p egnan women. In J Gynaecol Obs e .
(2021) 154:291–6. doi: 10.1002/ijgo.13713
8. Pa sons DJ, G imley DC, A he on PH, Cla ke L, Hillman DS, Bick PD. Wha
ac o s in luence he up ake o accina ions amongs p egnan women ollowing he
Co id-19 pandemic: a quali a i e s udy. Midwi e y. (2024) 134:104021. doi: 10.1016/j.
midw.2024.104021
9. Chinn J, Sedighim S, Ki by KA, Hohmann S, Hameed AB, Jolley J, e al.
Cha ac e is ics and ou comes o women wi h COVID-19 gi ing bi h a US academic
cen e s du ing he COVID-19 pandemic. JAMA Ne w Open. (2021) 4:e2120456. doi:
10.1001/jamane wo kopen.2021.20456
10. Allo ey J, S allings E, Bone M, Yap M, Cha e jee S, Kew T, e al. Clinical
mani es a ions, isk ac o s, and ma e nal and pe ina al ou comes o co ona i us disease
FIGURE2
The cen al ocus o he in o ma ion (i) e ol es a ound h ee p ima y hemes: socie al mo i a ion, ambigui y o in o ma ion and he heal h
consequences o p egnan indi iduals all in e wined wi h each o he .
102
Zil e e al. 10.3389/ pubh.2024.1415548
F on ie s in Public Heal h 10 on ie sin.o g
2019in p egnancy: li ing sys ema ic e iew and me a-analysis. BMJ. (2020) 370:m3320.
doi: 10.1136/bmj.m3320
11. Villa J, A i S, Gunie RB, Thi u engadam R, Rauch S, Kholin A, e al. Ma e nal
and neona al mo bidi y and mo ali y among p egnan women wi h and wi hou
COVID-19 in ec ion: he INTERCOVID mul ina ional coho s udy. JAMA Pedia .
(2021) 175:817–26. doi: 10.1001/jamapedia ics.2021.1050
12. Faja do-Ma inez V, Fe ei a F, Fulle T, Cambou MC, Ke in T, Paiola S, e al.
Neu ode elopmen al delay in child en exposed o ma e nal SARS-CoV-2 in-u e o. Sci
Rep. (2024) 14:11851. doi: 10.1038/s41598-024-61918-2
13. Bianchi DW, Kaese L, Ce nich AN. In ol ing p egnan indi iduals in clinical
esea ch on COVID-19 accines. JAMA. (2021) 325:1041–2. doi: 10.1001/
jama.2021.1865
14. Shimabuku o TT, Kim SY, Mye s TR, Mo o PL, Oduyebo T, Panagio akopoulos L,
e al. P elimina y indings o mRNA Co id-19 accine sa e y in p egnan pe sons. N
Engl J Med. (2021) 384:2273–82. doi: 10.1056/NEJMoa2104983
15. Collie AY, McMahan K, Yu J, Tos anoski LH, Aguayo R, Ansel J, e al.
Immunogenici y o COVID-19 mRNA accines in p egnan and lac a ing women.
JAMA. (2021) 325:2370–80. doi: 10.1001/jama.2021.7563
16. P asad S, Kala a E, Blakeway H, Townsend R, O'B ien P, Mo is E, e al. Sys ema ic
e iew and me a-analysis o he e ec i eness and pe ina al ou comes o COVID-19
accina ion in p egnancy. Na Commun. (2022) 13:2414. doi: 10.1038/
s41467-022-30052-w
17. Hillson K, Clemens SC, Madhi SA, Voysey M, Polla d AJ, Minassian AM. Fe ili y
a es and bi h ou comes a e ChAdOx1 nCoV-19 (AZD1222) accina ion. Lance .
(2021) 398:1683–4. doi: 10.1016/S0140-6736(21)02282-0
18. RCOG. RCOG COVID-19 accina ion guidance imeline. (2021). A ailable a :
h ps://www. cog.o g.uk/media/k5aniwh1/ cog-co id-19- accina ion-guidance-
imeline.pd .
19. COVID-19 Vaccines While P egnan o B eas eeding. A ailable a : h ps://www.
cdc.go /co ona i us/2019-nco / accines/ ecommenda ions/p egnancy.h ml.
20. Simeone RM, Zamb ano LD, Halasa NB, Fleming-Du a KE, Newhams MM, Wu
MJ, e al. E ec i eness o ma e nal mRNA COVID-19 accina ion du ing p egnancy
agains COVID-19-associa ed hospi aliza ions in in an s aged <6 mon hs du ing SARS-
CoV-2 omic on p edominance – 20 s a es, Ma ch 9, 2022–May 31, 2023. MMWR Mo b
Mo al Wkly Rep. (2023) 72:1057–64. doi: 10.15585/mmw .mm7239a3
21. Kie e MK, Mehl R, Cos an ine MM, Johnson A, Cohen J, Summe ield TL, e al.
Cha ac e is ics and pe cep ions associa ed wi h COVID-19 accina ion hesi ancy
among p egnan and pos pa um indi iduals: a c oss-sec ional s udy. BJOG. (2022)
129:1342–51. doi: 10.1111/1471-0528.17110
22. Bha acha ya O, Siddiquea BN, She y A, A oz A, Billah B. COVID-19 accine
hesi ancy among p egnan women: a sys ema ic e iew and me a-analysis. BMJ Open.
(2022) 12:e061477. doi: 10.1136/bmjopen-2022-061477
23. MacDonald NE. Vaccine hesi ancy: de ini ion, scope and de e minan s. Vaccine.
(2015) 33:4161–4. doi: 10.1016/j. accine.2015.04.036
24. Shmueli L. P edic ing in en ion o ecei e COVID-19 accine among he gene al
popula ion using he heal h belie model and he heo y o planned beha io model.
BMC Public Heal h. (2021) 21:804. doi: 10.1186/s12889-021-10816-7
25. Sa an aki A, Kaloge opoulou VE, Taskou C, Nanou C, Lyke idou A. COVID-19
accina ion and ela ed de e minan s o hesi ancy among p egnan women: a sys ema ic
e iew and Me a-analysis. Vaccines (Basel). (2022) 10:2055. doi: 10.3390/ accines10122055
26. Khan S, Sohan K, Mohammed ZCM, Bachan V. COVID-19 accine up ake,
accep ance, and easons o accine hesi ancy: a c oss-sec ional s udy among p egnan
women in T inidad, Wes Indies. In J Womens Heal h. (2023) 15:343–54. doi: 10.2147/
IJWH.S396884
27. Siegel MR, Lumb e as-Ma quez MI, James K, McBay BR, G ay KJ, Schan z-Dunn
J, e al. Pe cep ions and a i udes owa d COVID-19 accina ion among p egnan and
pos pa um indi iduals. Am J Pe ina ol. (2022) 29:1489–95. doi: 10.1055/a-1877-5880
28. Pa el A, Puglisi JL, Pa el S, Ta n DM. COVID-19 accine accep ance in p egnan
women in he Uni edS a es: a sys ema ic e iew and Me a-analysis. J Womens Heal h
(La chm ). (2024) 33:453–66. doi: 10.1089/jwh.2023.0498
29. Che enak FA, McCullough LB, G ünebaum A. Re e sing physician hesi ancy o
ecommend COVID-19 accina ion o p egnan pa ien s. Am J Obs e Gynecol. (2022)
226:805–12. doi: 10.1016/j.ajog.2021.11.017
30. Ji M, Anan hak ishnan A, McKee M, Wou e s OJ, Beu els P, Tee awa ananon Y.
Mul i-coun y collabo a ion in esponding o global in ec ious disease h ea s: lessons
o Eu ope om he COVID-19 pandemic. Lance Reg Heal h Eu . (2021) 9:100221. doi:
10.1016/j.lanepe.2021.100221
31. Ma ani M, Ka ul GG, Pan WK, Pa ola i AJ. In ensi y and equency o ex eme
no el epidemics. P oc Na l Acad Sci USA. (2021) 118:e2105482118. doi: 10.1073/
pnas.2105482118
32. B aun V, Cla ke V. Using hema ic analysis in psychology. Qual Res Psychol. (2006)
3:77–101. doi: 10.1191/1478088706qp063oa
33. G een J, Tho ogood N Quali a i e me hods o heal h esea ch. SAGE Publica ions
Inc. (2018).
34. Limbu YB, Gau am RK, Pham L. The heal h belie model applied o COVID-19
accine hesi ancy: a sys ema ic e iew. Vaccines (Basel). (2022) 10:973. doi: 10.3390/
accines10060973
35. Cla k S, Weale A. Social alues in heal h p io i y se ing: a concep ual amewo k.
J Heal h O gan Manag. (2012) 26:293–316. doi: 10.1108/14777261211238954
36. Wo ld Heal h O ganiza ion. Repo o he sage wo king g oup on accine
hesi ancy. (2022). A ailable a : h ps:// hecompass o sbc.o g/sbcc- ools/ epo -sage-
wo king-g oup- accine-hesi ancy.
37. Gibson A, Rand C, Olson-Chen C. A i udes owa d COVID-19 accina ion among
p egnan pe sons in U ban Hospi al-a ilia ed p ac ices: explo ing hemes in accine
hesi ancy. Ma e n Child Heal h J. (2023) 27:1855–63. doi: 10.1007/s10995-023-03752-y
38. Uludağ E, Se çekuş P, Yıldı ım DF, Özkan S. A quali a i e s udy o p egnan
women's opinions on COVID-19 accines in Tu key. Midwi e y. (2022) 114:103459. doi:
10.1016/j.midw.2022.103459
39. Ande son E, B igden A, Da ies A, Shephe d E, Ing am J. Ma e nal accines du ing
he Co id-19 pandemic:a quali a i e in e iew s udy wi h UK p egnan women.
Midwi e y. (2021) 100:103062. doi: 10.1016/j.midw.2021.103062
40. Mae ens K, O ije MRP, Van Damme P, Leu idan E. Vaccina ion du ing p egnancy:
cu en and possible u u e ecommenda ions. Eu J Pedia . (2020) 179:235–42. doi:
10.1007/s00431-019-03563-w
41. Kennedy J. Populis poli ics and accine hesi ancy in Wes e n Eu ope: an analysis
o na ional-le el da a. Eu J Pub Heal h. (2019) 29:512–6. doi: 10.1093/eu pub/ckz004
42. Malik M, Baue -Maison N, Gua na G, D'Souza RD. Social media misin o ma ion
abou p egnancy and COVID-19 accines: a sys ema ic e iew. Med P inc P ac . (2024)
33:232–41. doi: 10.1159/000538346
103
F on ie s in Public Heal h 01 on ie sin.o g
In es iga ing he in luencing
ac o s o accina ion decisions
o newly de eloped and
es ablished accines: a
compa a i e s udy based on
la en class logi models in China
ShiyunChang , BiaoXu *, HailingXi and Yi anShao
School o Go e nmen , Nanjing Uni e si y, Nanjing, China
Backg ound: The ac o s in luencing accina ion decision-making o newly
de eloped accines may besimila o and di e en om hose o es ablished
accines. Unde s anding hese unde lying di e ences and simila i ies is c ucial
o designing a ge ed measu es o p omo e new accines agains po en ial
no el i uses.
Objec i e: This s udy aims o compa e public accina ion decisions o
newly de eloped and es ablished accines and o iden i y he di e ences and
simila i ies in he in luencing ac o s.
Me hod: A disc e e choice expe imen (DCE) was conduc ed on 1,509
ep esen a i es o he gene al popula ion in China o collec da a on p e e ences
o he co ona i us disease 2019 (COVID-19) and in luenza accines, ep esen ing
he newly de eloped and es ablished accines, espec i ely. The la en class
logi model was used o iden i y la en classes wi hin he sample, allowing o an
analysis o he ac o s dis inc ly in luencing choices o bo h ypes o accines.
Resul : Pa icipan s alued simila a ibu es o bo h accines. Howe e , conce ns
abou sequelae we e mo e signi ican o he newly de eloped accine, while
e ec i eness was p io i ized o he es ablished accine. Class membe ship
analysis e ealed hese di e ences and simila i ies we e signi ican ly co ela ed
wi h age, heal h, yea ly household income, acquain ances’ accina ion s a us,
and isk pe cep ion.
Conclusion: The s udy highligh s he need o ailo ed communica ion
s a egies and a ge ed accina ion in e en ions. Fo he newly de eloped
accines, add essing conce ns abou side e ec s is mo e c ucial. Fo long-
s anding accines, emphasizing hei e ec i eness can enhance up ake mo e
signi ican ly. Engaging heal hca e p o ide s and communi y in luence s is
essen ial o bo h accines o inc ease public con idence and accina ion a es.
Clea communica ion and communi y engagemen a e c i ical s a egies o
add essing public conce ns and misin o ma ion, pa icula ly du ing pe iods o
heigh ened conce n.
KEYWORDS
COVID-19 accines, in luenza accines, la en class logi model, choice expe imen ,
accine p e e ences
OPEN ACCESS
EDITED BY
Ca los Albe o De Oli ei a Magalhães Júnio ,
S a e Uni e si y o Ma ingá, B azil
REVIEWED BY
Galal Me wally,
Zagazig Uni e si y, Egyp
Daniel Ga ie o,
Uni e si y o De by, Uni edKingdom
*CORRESPONDENCE
Biao Xu
[email p o ec ed]
RECEIVED 27 June 2024
ACCEPTED 09 Augus 2024
PUBLISHED 29 Augus 2024
CITATION
Chang S, Xu B, Xi H and Shao Y (2024)
In es iga ing he in luencing ac o s o
accina ion decisions o newly de eloped
and es ablished accines: a compa a i e
s udy based on la en class logi models in
China.
F on . Public Heal h 12:1455718.
doi: 10.3389/ pubh.2024.1455718
COPYRIGHT
© 2024 Chang, Xu, Xi and Shao. This is an
open-access a icle dis ibu ed unde he
e ms o he C ea i e Commons A ibu ion
License (CC BY). The use, dis ibu ion o
ep oduc ion in o he o ums is pe mi ed,
p o ided he o iginal au ho (s) and he
copy igh owne (s) a e c edi ed and ha he
o iginal publica ion in his jou nal is ci ed, in
acco dance wi h accep ed academic
p ac ice. No use, dis ibu ion o ep oduc ion
is pe mi ed which does no comply wi h
hese e ms.
TYPE O iginal Resea ch
PUBLISHED 29 Augus 2024
DOI 10.3389/ pubh.2024.1455718
104
Chang e al. 10.3389/ pubh.2024.1455718
F on ie s in Public Heal h 08 on ie sin.o g
The esul s o he in luenza g oup align wi h mos in luenza
s udies (18, 66). The pe cep ion ha an es ablished accine is sa e
han a as -paced, de eloped accine con ibu ed o lis ing sequelae as
he i s p io i y (8). In luenza accines a e o en pe cei ed wi h less
unce ain y due o he a ailabili y o long- e m da a. In con as ,
COVID-19 accines a e iewed wi h g ea e conce n. The di e ences
in isk pe cep ion lead o di e en accine p e e ences and decision-
making (8, 9, 52, 67–69).
The p e e ences inco po a ed wi h class membe ship sugges ha
popula ions wi h a ying cha ac e is ics exhibi he e ogeneous
p e e ences. Acco ding o he esul s o he COVID-19 accine
subg oup, younge esponden s belonging o Class
1
2, compa ed o
olde samples in o he classes, a ached mo e weigh o he p o ec ion
du a ion. Responden s wi h di e en le els o income had dis inc
a i udes owa d he o igin and ou -o -pocke cos s. Class1 1 ea ning
mo e money p e e ed impo ed COVID-19 accines and ga e li le
TABLE5 Fou classes in he COVID-19 accine g oup.
COVID-19 accine (N = 746)
Class11 2 3 4
Sha e 9.52% 35.22% 25.66% 29.60%
A ibu e OR 95% CI OR 95% CI OR 95% CI OR 95% CI
E ec i eness (base: 75%)
95% 2.21a1.87, 2.62 1.60a1.58, 1.62 1.03a1.02, 1.03 1.19a1.08, 1.32
P o ec ion du a ion (base: 6 mon hs)
1 yea NS 1.29a1.26, 1.33 0.98b0.97, 0.99 0.90b0.83, 0.98
5 yea s 1.99a1.32, 3.04 4.07a3.92, 4.23 NS NS
Sequelae p obabili y (base: high)
Middle 2.21a1.68, 2.90 NS 1.02a1.00, 1.02 1.15a1.04, 1.28
Low 4.26a3.05, 5.94 5.21a4.99, 5.43 NS 1.36a1.16, 1.61
Coun y-o -o igin (base: impo ed)
Domes ic 0.54a0.45, 0.66 NS NS 0.93a0.90, 0.97
Ou -o -pocke cos (CNY) (base:0)
150 NS 0.39a0.38, 0.40 1.04a1.03, 1.06 0.92a0.88, 0.97
300 NS 0.16a0.16, 0.17 1.03a1.01, 1.05 0.88a0.81, 0.96
Class membe ship Coe . 95% CI Coe . 95% CI Coe . 95% CI Baseline
Age NS −0.02a−0.03, −0.01 NS
Ma ied NS 0.54a0.20, 0.89 0.63a0.28, 0.97
Educa ion −1.70a−2.35, −1.04 NS NS
Unheal hy NS −0.33a−0.51, −0.16 −0.35a−0.54, −0.16
U ban egions NS −0.28c−0.58, 0.02 −0.84a−1.15, −0.53
Income (CNY) 0.51a0.24, 0.78 −0.19a−0.29, −0.09 NS
Vaccina ed acquain ances
Doc o s −1.65b−3.00, −0.30 0.63a0.24, 1.02 0.69a0.28, 1.10
Leade s 2.11a0.66, 3.57 NS −0.54b−1.02, 0.10
COVID-19 in ec ion
Low p obabili y 0.43a0.05, 0.81 NS NS
Mild ha m NS −0.49a−0.65, −0.32 NS
Vaccine sequelae
Low p obabili y NS −0.13b−0.25, −0.01 NS
Mild NS 0.25a0.13, 0.38 0.14b0.00, 0.28
Obse a ions 14,920
Only signi ican a iables we e displayed.
Class1: Class in he COVID-19 accine g oup.
a Signi icance: p < 0.01.
b Signi icance: p < 0.05.
c Signi icance: p < 0.1.
111
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