Insights into vaccine hesitancy from systems thinking,Rwanda

ObjectiveTo investigate vaccine hesitancy leading to underimmunization and a measles outbreak in Rwanda and to develop a conceptual, community-level model of behavioural factors.MethodsLocal immunization systems in two Rwandan communities (one recently experienced a measles outbreak) were explored using systems thinking, human-centred design and behavioural frameworks. Data were collected between 2018 and 2020 from: discussions with 11 vaccination service providers (i.e. hospital and health centre staff); interviews with 161 children’s caregivers at health centres; and nine validation interviews with health centre staff. Factors influencing vaccine hesitancy were categorized using the 3Cs framework: confidence, complacency and convenience. A conceptual model of vaccine hesitancy mechanisms with feedback loops was developed.FindingsA comparison of service providers’ and caregivers’ perspectives in both rural and peri-urban settings showed that similar factors strengthened vaccine uptake: (i) high trust in vaccines and service providers based on personal relationships with health centre staff; (ii) the connecting role of community health workers; and (iii) a strong sense of community. Factors identified as increasing vaccine hesitancy (e.g. service accessibility and inadequate follow-up) differed between service providers and caregivers and between settings. The conceptual model could be used to explain drivers of the recent measles outbreak and to guide interventions designed to increase vaccine uptake.ConclusionThe application of behavioural frameworks and systems thinking revealed vaccine hesitancy mechanisms in Rwandan communities that demonstrate the interrelationship between immunization services and caregivers’ vaccination behaviour. Confidence-building social structures and context-dependent challenges that affect vaccine uptake were also identified.     

Factors influencing vaccine acceptance and hesitancy in three informal settlements in Lusaka,Zambia

IntroductionHeterogeneous coverage threatens to compromise the effectiveness of immunization programs in Zambia. Demand-creation initiatives are needed to address this; however, there is incomplete understanding of why vaccine coverage is suboptimal. We investigated overarching perceptions on vaccine acceptability, hesitancy, and accessibility at three informal settlements in Lusaka, Zambia.MethodsNested within a cholera vaccination uptake study, we sought to understand overarching perceptions on vaccines’ hesitancy in three informal settlements in Lusaka, Zambia. We conducted 48 focus group discussions with a convenience sample of laypersons, lay healthcare workers, neighbourhood health committee members and vaccinators.ResultsBoth laypersons and community-based health actors reported high vaccine acceptance though several sources of hesitancy were reported. Traditional remedies, alcohol use and religious beliefs emerged as drivers of vaccine hesitancy, likely reinforced by a background of distrust towards western medicine. Also mentioned were previous adverse events, fear of injections and low perceived need for immunization. Limited understanding of how vaccines work and overlapping local terms for vaccine and other medical concepts created confusion and inaccurate views and expectations. Some reported refusing injections to avoid pain and perceived risk of infection. Discussants emphasised the importance of education and preferred mobile immunization campaigns, with weekend to reach those with poor access and delivered by a combination of professional and volunteer workers.ConclusionsVaccine hesitancy in Zambia is underpinned by many factors including personal experiences with vaccinations, alternative belief models, limited knowledge, deep misunderstanding about how vaccines work, and barriers to access. To overcome these, community-driven models that incorporate factual communication by professionals and operate outside of traditional hours, may help. Better research to understand community preferences for vaccine uptake could inform interventions to improve immunization coverage in Zambia.     

Misinformation and COVID-19 vaccine hesitancy

BackgroundCOVID-19 vaccine hesitancy has emerged as a major public health challenge. Although medical and scientific misinformation has been known to fuel vaccine hesitancy in the past, misinformation surrounding COVID-19 seems to be rampant, and increasing evidence suggests that it is contributing to COVID-19 vaccine hesitancy today. The relationship between misinformation and COVID-19 vaccine hesitancy is complex, however, and it is relatively understudied.MethodsIn this article, we report qualitative data from two related but distinct studies from a larger project. Study 1 included semi-structured, open-ended interviews conducted in October–November 2020 via phone with 30 participants to investigate the relationship between misinformation and COVID-19 vaccine hesitancy. Study 1′s results then informed the design of open-ended questions for Study 2, an online survey conducted in May–June 2021 to consider the relationship between misinformation and vaccine hesitancy further. The data were examined with thematic analysis.ResultsStudy 1 led to the identification of positive and negative themes related to attitudes toward COVID-19 vaccines. In Study 2, responses from vaccine-hesitant participants included six categories of misinformation: medical, scientific, political, media, religious, and technological. Across both Study 1 and Study 2, six vaccine hesitancy themes were identified from the data: concerns about the vaccines’ future effects, doubts about the vaccines’ effectiveness, commercial profiteering, preference for natural immunity, personal freedom, and COVID-19 denial.ConclusionsThe relationship between misinformation and vaccine hesitancy is complicated. Various types of misinformation exist, with each related to a specific type of vaccine hesitancy-related attitude. Personal freedom and COVID-19 denial are vaccine attitudes of particular interest, representing important yet understudied phenomena. Medical and scientific approaches may not be sufficient to combat misinformation based in religion, media, or politics; and public health officials may benefit from partnering with experts from those fields to address harmful misinformation that is driving COVID-19 vaccine hesitancy.     

Exploring key informants’ perceptions of Covid-19 vaccine hesitancy in a disadvantaged urban community in Ireland: Emergence of a ‘4Cs’ model

AimThe aim of this study was to explore key informants’ views on and experiences with Covid-19 vaccine hesitancy in a Dublin community with a high concentration of economic and social disadvantage and to identify feasible, community-centred solutions for improving vaccination acceptance and uptake.MethodsQualitative, semi-structured interviews were carried out at a local community-centre and a central hair salon. Twelve key informants from the target community were selected based on their professional experience with vulnerable population groups: the unemployed, adults in recovery from addiction, the elderly, and Irish Travellers. Inductive thematic framework analysis was conducted to identify emergent themes and sub-themes.ResultsDrivers of vaccine hesitancy identified by key informants largely fell under the WHO ‘3Cs’ model of hesitancy: lack of confidence in the vaccine and its providers, complacency towards the health risks of Covid-19, and inconvenient access conditions. Covid-19 Communications emerged as a fourth ‘C’ whereby unclear and negative messages, confusing public health measures, and unmet expectations of the vaccine’s effectiveness exacerbated anti-authority sentiments and vaccine scepticism during the pandemic. Community-specific solutions involve the provision of accurate and accessible information, collaborating with community-based organizations to build trust in the vaccine through relationship building and ongoing dialogue, and ensuring acceptable access conditions.ConclusionsThe proposed Confidence, Complacency, Convenience, Covid-19 Communications (‘4Cs’) model provides a tool for considering vaccine hesitancy in disadvantaged urban communities reacting to the rapid development and distribution of a novel vaccine. The model and in-depth key informants’ perspectives can be used to compliment equitable vaccination efforts currently underway by public health agencies and non-governmental organizations.     

The effect of health literacy on COVID-19 vaccine hesitancy among community population in China: The moderating role of stress

BackgroundThe public’s hesitant attitude is a major subjective barrier in promoting vaccination against COVID-19 to build herd immunity. The current study aimed to address how individual factors such as health literacy and perceived stress affect people’s vaccine hesitancy of COVID-19 vaccine, and to provide insights for tailoring vaccine-promotion strategies.MethodsWith structured questionnaires, an online survey was conducted to address the relationship between the health literacy, perceived stress, and COVID-19 vaccine hesitancy among community population in mainland, China. Moderated analysis was conducted to test the effect of health literacy on vaccine hesitancy among people with different levels of perceived stress.Results560 responses were collected in total. 39.8% of the participants reported vaccine hesitancy, and this rate was higher among younger people and female. Moreover, people with higher level of health literacy showed reduced vaccine hesitancy, while this effect was only significant among those with low or moderate level of stress. For people with high level of stress, no significant effect of health literacy was found.ConclusionsThe findings suggest that increasing people’s health literacy could lead to reduced vaccine hesitancy in community sample. However, this effect disappeared when the stress level was high, suggesting other promotion services may need to be developed to increase the acceptance of COVID-19 vaccine. In conclusion, vaccine promotion strategies should be tailored for different populations, with taking account of individual’s health literacy and perceived stress.     

The effects of parent’s health literacy and health beliefs on vaccine hesitancy

Parental vaccine hesitancy is a key factor influencing children’s vaccination against infectious diseases such as the COVID-19. The current study aims to investigate how parent’s health literacy and health belief affect parental hesitancy toward the COVID-19 vaccination, and navigate effective measures to help parents make vaccination decision for children. A mixed-mode web survey was conducted among parents of children aged 3–11 years. Parental vaccine hesitancy, health literacy, and health beliefs were assessed. Parallel mediation model examined whether the association between parent's health literacy and vaccine hesitancy was mediated by health beliefs. In total, 11.3% of the 346 participants reported vaccine hesitancy. Hesitant parents were more likely to be he mother (Father: 4.5%; Mother: 12.9%) and with children having allergic issues (Allergic: 18.3%; Non-allergic: 9.8%). Meanwhile, parents with lower health literacy were more likely to show hesitancy towards vaccinating their children (β = −6.87, 95% CI = [−10.50, −3.11]). This relationship was partially mediated by more perceived barriers in vaccination (β = −2.53, 95%CI = [−4.09, −1.02]), but not other health beliefs. In other words, parents with better health literacy may perceive fewer barriers in making vaccination decision for their children, thus being less hesitant. Accordingly, healthcare professionals and policy makers could design education service to promote parents’ health literacy, and remove the perceived barriers as well as increase their confidence in following the COVID-19 vaccine guidance for children.     

Point-of-care vaccinators’ perceptions of vaccine hesitancy drivers: A qualitative study from the cape metropolitan district,South Africa

BackgroundVaccination coverage remains suboptimal in many parts of the world, especially in low-and middle-income countries (LMICs), including South Africa. Vaccine hesitancy, a recognized factor contributing to low vaccination uptake in many parts of the world, is suspect in the suboptimal vaccination coverage level in South Africa, particularly in the Western Cape Province. We aimed to investigate vaccine hesitancy and to describe point-of-care vaccinators’ perceptions of the drivers of vaccine hesitancy in the Cape Metropolitan District, South Africa (Cape Metro).We conducted in-depth interviews with 19 point-of-care vaccinators in 16 purposively selected healthcare facilities in the Cape Metro between September and November 2019. Participants were sampled purposively as ‘rich cases’ who had been delivering vaccination services for at least five years post-qualification. We organized the data thematically in ATLAS.ti and report findings thematically by the types of reasons participants reported for vaccine hesitancy amongst clients.FindingsOf the 19 interviewees, 11 (59%) reported having encountered vaccine-hesitant clients at some point in their careers. Reasons reported for vaccine hesitancy by clients included: (a) religion, (b) internet misinformation, (c) concern over causing the child pain, (d) natural immunity development, and (e) concern about possible adverse effect following immunization. Vaccine hesitancy in the Cape Metro cuts across all socio-economic classes. Also, some communities perceived to be vaccine-hesitant were mentioned by the participants in this study.ConclusionsAttitude towards vaccination are generally positive in the Cape Metro. However, vaccine hesitancy is present. The issues of vaccine hesitancy at the reported levels can still be mitigated by continuous health education in the clinics and communities, as well as stakeholder engagement as suggested by the point-of-care vaccinators in the Cape Metro.     

Towards a predictive model of COVID-19 vaccine hesitancy among American adults

Designing effective public health campaigns to combat COVID-19 vaccine hesitancy requires an understanding of i) who the vaccine hesitant population is, and ii) the determinants of said population’s hesitancy. While researchers have identified a number of variables associated with COVID-19 vaccine hesitancy that could inform such campaigns, little is known about the cumulative or relative predictive power of these factors. In this article, we employ a machine learning model to analyze online survey data collected from 3353 respondents. The model incorporates an array of variables that have been shown to impact vaccine hesitancy, allowing us to i) test how well we can predict vaccine hesitancy, and ii) compare the relative predictive impact of each covariate. The model allows us to correctly classify individuals that are vaccine acceptant with 97% accuracy, and those that are vaccine hesitant with 72% accuracy. Trust in and knowledge about vaccines is, by far, the strongest predictor of vaccination choice. While our results demonstrate that public health campaigns designed to increase vaccination rates must find a way to increase public trust in COVID-19 vaccines, our results cannot speak to the malleability of such beliefs, nor how to enhance trust.     

Association among trust in health care providers,friends, and family,and vaccine hesitancy

A health care provider’s vaccination recommendation is one of the most important factors influencing parents’ decisions about whether to vaccinate their children. Unfortunately, vaccine hesitancy is associated with mistrust of health care providers and the medical system. We conducted a survey of 2440 adults through the RAND American Life Panel in 2019. Respondents were asked to rate their trust in pediatricians, OB/GYNs, doulas, midwives, lactation consultants, friends and family for information about childhood vaccines. Respondents were also asked about willingness to vaccinate a hypothetical child as a measure of vaccine hesitancy. We used principal component analysis to characterize variance in responses on trust items and logistic regression to model the relationship between trust and vaccine hesitancy. Vaccine hesitancy was associated with: (1) lower overall trust; (2) reduced trust in OB/GYNs and pediatricians and greater trust in doulas, midwives, and lactation consultants; and (3) greater trust in friends and family.     

Prevalence and characteristics of HPV vaccine hesitancy among parents of adolescents across the US

BackgroundWhile many clinicians encounter parents or adolescents who refuse HPV vaccine, little is known about the prevalence of hesitancy for HPV vaccine nationally or its association with vaccination.MethodsIn April 2019, we surveyed families with adolescents 11–17 years using a national online panel (Knowledge Panel®) as the sampling frame. We assessed the prevalence of HPV vaccine hesitancy with the validated 9-item Vaccine Hesitancy Scale (VHS). We used multivariate analyses to assess demographic factors associated with HPV vaccine hesitancy. We also assessed practical barriers to receipt of HPV vaccine and the relationship between barriers and hesitancy. Finally, we evaluated the association between both HPV vaccine hesitancy and practical barriers on HPV vaccine receipt or refusal.Results2,177 parents out of 4,185 sampled (52%) completed the survey, 2,020 qualified (lived with adolescent). Using a VHS cut-off score > 3 out of 5 points, 23% of US parents were hesitant about HPV vaccine. Hesitancy was lower among those with Hispanic ethnicity. At least one out of five parents disagreed that the HPV vaccine is beneficial for their adolescent, that the vaccine is effective, protects against HPV-related cancers, or that they followed their adolescent’s health-care provider’s recommendation about the vaccine. Many were concerned about vaccine side effects and the novelty of the vaccine. Adolescents living with vaccine-hesitant parents were less than one-third as likely to have received the vaccine (RR = 0.29, 95% CI 0.24, 0.35) or completed the vaccine series (RR = 0.29, 95% CI 0.23, 0.36), and were 6-fold more likely to have refused the vaccine because of parental vaccine-related concerns (RR = 6.09, 95% CI = 5.26, 7.04). Most practical barriers were independently associated with vaccine receipt but not with vaccine refusal.ConclusionsHPV vaccine hesitancy is common nationally and strongly related to both under-vaccination and vaccine refusal.     

A behavior change model to address caregiver hesitancy around COVID-19 vaccination in pediatrics

IntroductionMany families express hesitancy around immunizing their children against COVID-19. We sought to better understand the perspectives of vaccine hesitant caregivers, and develop targeted recommendations for health care workers and policymakers to engage in more effective vaccine discussions.MethodsWe conducted semi-structured telephone interviews with 23 caregivers recruited from a pediatric infectious diseases clinic, including a subset of patients referred to discuss vaccine hesitancy. Thematic analysis of the interviews identified themes that were mapped using behavior change models to identify perceived barriers and facilitators towards COVID-19 immunization.ResultsBarriers and facilitators were mapped to the WHO (World Health Organization) 3C’s (confidence, complacency, convenience) model of vaccine hesitancy as well as the COM-B (capability, opportunity, motivation) behavior change model. Barriers included mistrust in authorities, misperception of the risk of COVID-19 in children, and perceived health contraindications and negative previous vaccine experiences. Facilitators included positive relationships with healthcare workers, the promise of a “return to normal”, and societal pressures to immunize.ConclusionsEfforts to increase vaccine uptake in the pediatric population must target specific barriers and facilitators to immunization expressed by caregivers. To address these concerns, we suggest: 1. Educating hesitant caregivers by highlighting the long-term pandemic effects on children and the threat of COVID-19 to children’s health, 2. Building on the trust caregivers have in healthcare workers by involving frontline workers in public health policy, and 3. Harnessing the power of peer pressure by mobilization of societal pressures and establishing COVID-19 vaccination as the norm in children.     

Factors influencing Covid-19 vaccine acceptance across subgroups in the United States: Evidence from a conjoint experiment

Public health officials warn that the greatest barrier to widespread vaccination against Covid-19 will not be scientific or technical, but the considerable public hesitancy to take a novel vaccine. Understanding the factors that influence vaccine acceptance is critical to informing public health campaigns aiming to combat public fears and ensure broad uptake. Employing a conjoint experiment embedded on an online survey of almost 2,000 adult Americans, we show that the effects of seven vaccine attributes on subjects’ willingness to vaccinate vary significantly across subgroups. Vaccine efficacy was significantly more influential on vaccine acceptance among whites than among Blacks, while bringing a vaccine to market under a Food and Drug Administration Emergency Use Authorization had a stronger adverse effect on willingness to vaccinate among older Americans and women. Democrats were more sensitive to vaccine efficacy than Republicans, and both groups responded differently to various endorsements of the vaccine. We also explored whether past flu vaccination history, attitudes toward general vaccine safety, and personal contact with severe cases of Covid-19 can explain variation in group vaccination hesitancy. Many subgroups that exhibit the greatest Covid-19 vaccine hesitancy did not report significantly lower frequencies of flu vaccination. Several groups that exhibited greater Covid-19 vaccine hesitancy also reported greater concerns about vaccine safety generally, but others did not. Finally, subgroup variation in reported personal contact with severe cases of Covid-19 did not strongly match subgroup variation in vaccine acceptance.     

A rapid qualitative assessment of oral cholera vaccine anticipated acceptability in a context of resistance towards cholera intervention in Nampula,Mozambique

IntroductionWhile planning an immunization campaign in settings where public health interventions are subject to politically motivated resistance, designing context-based social mobilization strategies is critical to ensure community acceptability. In preparation for an Oral Cholera Vaccine campaign implemented in Nampula, Mozambique, in November 2016, we assessed potential barriers and levers for vaccine acceptability.MethodsQuestionnaires, in-depth interviews, and focus group discussions, as well as observations, were conducted before the campaign. The participants included central and district level government informants (national immunization program, logistics officers, public health directors, and others), community leaders and representatives, and community members.ResultsDuring previous well chlorination interventions, some government representatives and health agents were attacked, because they were believed to be responsible for spreading cholera instead of purifying the wells. Politically motivated resistance to cholera interventions resurfaced when an OCV campaign was considered. Respondents also reported vaccine hesitancy related to experiences of problems during school-based vaccine introduction, rumors related to vaccine safety, and negative experiences following routine childhood immunization. Despite major suspicions associated with the OCV campaign, respondents’ perceived vulnerability to cholera and its perceived severity seem to override potential anticipated OCV vaccine hesitancy.DiscussionPotential hesitancy towards the OCV campaign is grounded in global insecurity, social disequilibrium, and perceived institutional negligence, which reinforces a representation of estrangement from the central government, triggering suspicions on its intentions in implementing the OCV campaign. Recommendations include a strong involvement of community leaders, which is important for successful social mobilization; representatives of different political parties should be equally involved in social mobilization efforts, before and during campaigns; and public health officials should promote other planned interventions to mitigate the lack of trust associated with perceived institutional negligence. Successful past initiatives include public intake of purified water or newly introduced medication by social mobilizers, teachers or credible leaders.     

Access to HPV vaccination in Japan: Increasing social trust to regain vaccine confidence

Vaccine hesitancy is a growing concern in global public health, and illustrates serious problems arising from loss of social trust. Japan is experiencing a human papillomavirus (HPV) vaccine crisis that started with a rapid decline in the vaccination rate in 2013 from approximately 70% to less than 1% and lasting for 7 years. We analyze Japan’s case of vaccine hesitancy for HPV vaccine, using a framework for examining barriers to access and use of health technologies according to four categories: architecture, availability, affordability, and adoption. Significant problems were identified in the architecture of the decision-making body, public information availability, adoption of evidence in policy-making process, knowledge and confidence among providers, education to the public, and communication with end-users. We propose a series of actions to address these barriers. The national government should diversify the advisory committee to include broader scientific evidence and various viewpoints. Municipalities should actively distribute information cooperating with local providers. Professional associations should create an alliance to influence policy makers and deliver education to health care providers and end-users. Politicians should integrate opinions from citizens and scientists to implement an up-to-date policy. Civil society should share individual stories from cervical cancer patients and positive experiences of vaccinated girls. Mass media should use more diverse sources of information to report more comprehensive and science-based views. These actions would help build mutual trust among stakeholders, which is required to increase social trust in the HPV vaccine in Japan and thereby regain vaccine confidence and reduce preventable deaths and complications.     

Hesitancy to receive the novel coronavirus vaccine and potential influences on vaccination among a cohort of healthcare workers in the Democratic Republic of the Congo

Hesitancy to receive the COVID-19 vaccine among healthcare workers (HCWs) in low-resource settings, such as the Democratic Republic of the Congo (DRC), is a major global health challenge. This study identifies changes in willingness to receive vaccination among 588 HCWs in the DRC and reported influences on COVID-19 vaccination intentions. Up to 25 repeated measures were collected from participants between August 2020 to August 2021. Among the overall cohort, between August 2020 and mid-March 2021, the proportion of HCWs in each period of data collection reporting COVID-19 vaccine hesitancy ranged from 8.6% (95% CI: 5.97, 11.24) to 24.3% (95% CI: 20.12, 28.55). By early April 2021, the proportion reporting hesitancy more than doubled (52.0%; 95% CI: 46.22, 57.83). While hesitancy in the cohort began to decline by late-June 2021, 22.6% (95% CI: 18.05, 27.18) respondents indicated hesitancy in late-August 2021 which remains greater than the proportion of hesitancy at any time prior to early-March 2021. Patterns in reported influences on COVID-19 vaccination were varied with the proportion reporting some influences (e.g., no serious side effects, country of vaccine production) remaining stable throughout the year and other factors (e.g., recommendation of Ministry of Health, ease of vaccination) falling in popularity among respondents. Agreement that the national vaccination schedule should be followed apart from the COVID-19 vaccine remained high among respondents throughout the study period. This study shows that, among a cohort of HCWs in the DRC who have likely been influenced by regional, national, and global factors, COVID-19 vaccine hesitancy has fluctuated during the pandemic and should not be treated as a static factor. Additional research to determine which factors most influence HCWs’ willingness to receive the COVID-19 vaccine offers opportunities to reduce vaccine hesitancy among this important population through tailored public health messaging.     

Social media use and vaccine hesitancy in the European Union

Vaccine hesitancy can hinder the successful roll-out of vaccines. This paper examines COVID-19 vaccine hesitancy in the European Union, drawing from a large-scale cross-national survey covering all 27 EU Member States, carried out between February and March 2021 (n = 29,755). We study the determinants of vaccine hesitancy, focusing on the role of social media use. In multivariate regression models, we find statistically significant (p < 0.05) impacts on vaccine hesitancy of heavy use of social media and using social media as a main source of news. However, the effect of social media and the drivers of vaccine hesitancy vary depending on the reason for hesitancy. Most notably, hesitancy due to health concerns is mainly driven by physical health status and less by social media use, while views that COVID-19 risks are exaggerated (or that COVID-19 does not exist) are more common among men, people in good health, and those using social media as their main source of news.     

Overcoming COVID-19 vaccine hesitancy among ethnic minorities: A systematic review of UK studies

Ethnic minority communities in the UK have been disproportionately affected by the pandemic, with increased risks of infection, severe disease, and death. Hesitancy around the COVID-19 vaccine may be contributing to disparities in vaccine delivery to ethnic minority communities. This systematic review aims to strengthen understanding of COVID-19 vaccine concerns among ethnic minorities in the UK. Five databases were searched in February 2022, yielding 24 peer-reviewed studies reporting on vaccine hesitancy or acceptance in ethnic minority groups. Data were extracted using a standardised form, and quality assessment was carried out using the Standard Quality Criteria. There were three key themes: (1). Prevalence of vaccine hesitancy; (2). Reasons for vaccine hesitancy and acceptance; and (3). Recommendations to address vaccine concerns. Vaccine hesitancy, which was more common among some ethnic minority groups, is a complex phenomenon, driven by misinformation, mistrust, concerns about safety and efficacy, and structural and systemic inequities. Community engagement and tailored communication may help to address vaccine concerns. Robust data disaggregated by ethnicities are needed to better understand barriers and facilitators for COVID-19 vaccine delivery in ethnic minority communities. Strategies to address structural disadvantage need to be inclusive, comprehensive, and behaviorally informed and foster confidence in healthcare systems and governments. Community leaders and health care practitioners may prove to be the most important agents in creating an environment of trust within ethnic minority groups.     

The continuum of influenza vaccine hesitancy among nursing professionals in Hong Kong

IntroductionInfluenza vaccine hesitancy among healthcare workers poses challenges to the achievement of herd immunity and causes infection risks to vulnerable patients. This study aimed to quantify the extent of influenza vaccine hesitancy among nurses in Hong Kong, to delineate its pattern, and to explore its socio-demographic, professional and personal correlates.MethodNurses in Hong Kong were recruited in a cross-sectional study involving the administration of an online questionnaire survey after the 2017/18 winter influenza season. Respondents’ influenza vaccination behaviours, attitudes and psychological antecedents were assessed, followed by their delineation into subgroups along the hesitancy continuum through a combination of multiple correspondence analysis and K-means cluster analysis. Socio-demographic, professional and personal correlations of subgrouping were investigated using generalised ordered logistic regression.ResultsThe overall vaccination coverage of nurses for the 2017/18 influenza season was 44%. Five clusters were differentiated by the level of influenza vaccine hesitancy: “Very high hesitancy-to-complete refusal” (n = 56; 7%) characterised by outright refusal of vaccination; “High hesitancy” (n = 171; 23%) distinguished by tendency of skipping vaccination and scepticism about safety of vaccine; “Moderate hesitancy” (n = 273; 36%) with uncertainties towards vaccination, mistrust of the government’s vaccine recommendations and priority concern on affordability of vaccine; “Low hesitancy” (n = 95; 13%) with cautious acceptance towards vaccination and “No-to-minimal hesitancy” (n = 158; 21%) with strong vaccine confidence and compliance greatly linked to convenience of vaccine access. Nurses having completed at least 3 years’ pre-registration professional training, having most family members vaccinated against influenza, and with influenza vaccination history during studentship were less vaccine hesitant.ConclusionWith more than half of the nurses in Hong Kong having moderate or higher level of influenza vaccine hesitancy, interventions customised to the needs of nurses as reflected from the characteristics of clusters along the vaccine hesitancy continuum could form an important strategy for improving vaccination uptake.