Vaccine Hesitancy in Sri Lanka: A Growing Threat to Public Health Gains

Effective Approaches to Combat Vaccine Hesitancy.

“Is it my problem if my father-in-law does not want to get vaccinated?”All of us must have encountered scenarios like the above. We have all met individuals who refused or hesitate to get vaccinated for COVID-19. They could be from our family members, our colleagues, our friends, our employees, our neighbors, our school, or communities, from anywhere! We do not need to look far. What will we do? Or how should we approach these situations?For more than a year now, we have been witnessing the unfolding of the roll out of the “biggest” vaccine drives in history. Furthermore, this COVID-19 pandemic challenged every individual to make a personal stand about accepting and even promoting vaccination. This issue of the Acta Medica Philippina includes two contributions that give us different perspectives on the phenomenon called “Vaccine Hesitancy.” Vaccine hesitancy is reluctance or refusal to get vaccinated even with theavailability of vaccines.While vaccine hesitancy is observed across the world, our issue looks specifically at the factors which contribute to the unique experiences in the Southeast Asian region and even more specifically to our country. These discussions will lead to a better understanding of drivers, both barriers and enablers to vaccine acceptance and uptake. This timely sharing of information comes at that crucial period when the vaccine hesitancy rates are high in our country despite efforts of our government to persuade as many individuals as possible to come for their COVID-19 booster vaccines. The World Health Organization (WHO) released guidance for countries and governments on how they can improve the vaccine uptake of their constituents.1 In addition to addressing the need for up-to-date information campaigns, governments and other “actors” who play major roles in the implementation of the vaccination program, especially during the current pandemic, need to listen and attune themselves to the main drivers of vaccine acceptance versus hesitancy. These are: 1) providing an enabling environment, 2) social influences; and 3) motivation.The paper of Hartigan-Go and group shows vaccine hesitancy research and how this information may be used to strategize vaccine education and communication campaigns to increase vaccine uptake.2The invited essay is a discussion on how the traumatic experience we all witnessed in recent national history with another novel vaccine is an important driver negatively affecting behavior toward vaccination campaigns; and how can we move forward from there.3We hope these contributions will help us all appreciate and respect the complexity of behavior related to vaccination, persuade our countrymen towards action that will help us achieve our desired goals for more, and work towards attaining our goal of better health for all.
 Regina P. Berba, MD, MScHospital Infection Control Unit, Philippine General HospitalCollege of Medicine, University of the Philippines Manila
 
 REFERENCES
 1. Behavioural considerations for acceptance and uptake of COVID-19 vaccines: WHO Technical Advisory Group on Behavioural Insights and Sciences for Health, meeting report, 15 October 2020. Geneva: World Health Organization; 2020. License: CC BY-NC-SA 3.0 IGO.2. Hartigan-Go KY, Mendoza RU, Ong MMA, Yap JK. COVID-19 Vaccine hesitancy in ASEAN: Insights from a Multi-wave Survey Database from July 2020 to March 2021. Acta Med Philipp. 2023;57(1):10-16.3. Berba RP. Addressing vaccine hesitancy during the COVID-19 pandemic: Learning from the past and moving forward. Acta Med Philipp. 2023;57(1):4-9.

BACKGROUND:The World Health Organization (WHO) states that vaccine hesitancy is one of the top 10 threats to global public health. Evidence shows that vaccine hesitancy studies in India are limited and targeted toward individual vaccines. The study aimed to fill this gap by exploring the relationship between demographics and SAGE factors toward vaccine hesitancy.MATERIALS AND METHODS:A hospital-based, cross-sectional, analytical study was conducted in a non-governmental organization (NGO) hospital with 330 beds, located in Bathalapalli, Andhra Pradesh, India. Mothers of under-five children who attended outpatient departments of pediatrics or obstetrics and gynecology were included. A total of 574 mothers were enrolled and vaccine hesitancy was determined by reviewing the mother–child protection card for the presence of delay or refusal of the recommended vaccine. A face-to-face interview was conducted to obtain demographics and WHO–SAGE variables from the participants. Binary logistic regression analysis was performed to associate independent variables (demographics and SAGE variables) with the dependent variable (vaccine hesitancy).RESULTS:Out of 574 respondents, 161 mother's children were noted as vaccine-hesitant (refusal = 7; delay = 154); and the prevalence of vaccine hesitancy was 28.05%. The delay was observed in all recommended vaccines, but the refusal or reluctance was seen in only four vaccines (hepatitis B birth dose = 1; IPV 1 and 2 = 2; Measles 1 and 2 = 3; and Rota 1, 2, and 3 = 1). The respondents’ demographics like no or lower parent education (OR = 3.17; 95%CI = 1.50–6.72) and fewer antenatal visits (OR = 2.30; 95%CI = 1.45–3.36) showed higher odds, whereas the upper socioeconomic status showed lower odds (OR = 0.09; 95%CI = 0.02–0.36) toward vaccine hesitancy. The WHO–SAGE dimensions like awareness (OR = 0.14; 95%CI = 0.03–0.53), poor access (OR = 7.76; 95%CI = 3.65–16.51), and low acceptability of the individual (OR = 07.15; 95%CI = 1.87–27.29), community (OR = 6.21; 95%CI = 1.58–24.33) were significantly associated with vaccine hesitancy.CONCLUSION:The study concludes that the prevalence of vaccine hesitancy was high. Vaccine safety and children's health are primary concerns for parents’ refusal/reluctance. To achieve 100% immunization coverage, policymakers need to reduce vaccine hesitancy by developing strategies based on demographic and WHO–SAGE working group predictors.

Vaccine hesitancy was declared as one of the ten threats to global public health by the World Health Organization in 2019. It undermines the effort towards eradication of vaccine-preventable diseases. Healthcare providers, who are directly involved in vaccination services and vaccine advocacies, are important in combating vaccine hesitancy. Studies have shown that vaccine refusers have various reasons for refusal including distrust towards healthcare providers. Hence, it is important to understand healthcare providers' perspectives. This study aimed to explore primary healthcare providers (PHCPs)' experiences in dealing with vaccine hesitancy. This qualitative study was conducted among public PHCPs across six states in Malaysia. Purposive and snowball sampling methods were used. Fifteen primary healthcare doctors and nurses underwent in-depth interviews. Recruitment was stopped when data saturation was achieved. Data were thematically analysed. Four themes emerged: 1) views towards vaccination and vaccine hesitancy, 2) disparity in strategies and resources used among PHCPs, 3) fixed-minded vaccine deniers and religious incompatibility: the two towering hurdles and 4) negative impact after encounters with vaccine hesitancy. Malaysian PHCPs encounter negative experiences with vaccine hesitancy, impacting them negatively. These experiences are attributed to the challenges and lack of standardised resources for reference. These findings suggest the development of a more flexible policy, a training module inclusive of all professional roles and a standardised repository of resources for managing vaccine hesitancy.

BackgroundVaccines serve as a crucial public health tool, although vaccine hesitancy continues to pose a significant threat to full vaccine uptake and, consequently, community health. Understanding and tracking vaccine hesitancy is essential for effective public health interventions; however, traditional survey methods present various limitations.ObjectiveThis study aimed to create a real-time, natural language processing (NLP)–based tool to assess vaccine sentiment and hesitancy across 3 prominent social media platforms.MethodsWe mined and curated discussions in English from Twitter (subsequently rebranded as X), Reddit, and YouTube social media platforms posted between January 1, 2011, and October 31, 2021, concerning human papillomavirus; measles, mumps, and rubella; and unspecified vaccines. We tested multiple NLP algorithms to classify vaccine sentiment into positive, neutral, or negative and to classify vaccine hesitancy using the World Health Organization’s (WHO) 3Cs (confidence, complacency, and convenience) hesitancy model, conceptualizing an online dashboard to illustrate and contextualize trends.ResultsWe compiled over 86 million discussions. Our top-performing NLP models displayed accuracies ranging from 0.51 to 0.78 for sentiment classification and from 0.69 to 0.91 for hesitancy classification. Explorative analysis on our platform highlighted variations in online activity about vaccine sentiment and hesitancy, suggesting unique patterns for different vaccines.ConclusionsOur innovative system performs real-time analysis of sentiment and hesitancy on 3 vaccine topics across major social networks, providing crucial trend insights to assist campaigns aimed at enhancing vaccine uptake and public health.

The COVID-19 pandemic, which started in 2019, affected social, economic and political structures all over the world and pushed states to take quick and dramatic measures. Vaccine development studies, which are seen as the most effective way of combating such pandemics, started rapidly and mass vaccinations were started in a short time. However, the opposition to vaccines, which has been going on since the first days of the use of vaccines in the world, has come to the fore again against COVID-19 vaccine programs. Anti-vaccine rhetoric has slowed the pace of the fight against the pandemic. Field studies have shown that more than 50% of people experience hesitations about vaccination. The World Health Organization defines vaccine refusal or vaccine hesitancy as a global threat. Identifying the reasons for vaccine hesitancy is very important in terms of maintaining general public health. For this reason, social scientists are working on the causes of vaccine hesitancy. In the literature, religiosity and low level of education are shown among the reasons for vaccine hesitancy. However, when studies are examined, there are clues that a certain type of religiosity rather than religiosity is related to anti-vaccination. The main problem of this research is whether religiosity and education level predict COVID-19 vaccine hesitancy. In this study, the relationship between religiosity, dogmatic religiosity, education level, socio-economic level and COVID-19 awareness with vaccine hesitancy and their predictive levels are examined. The research is in correlational model and cross-sectional design. The relationship of five variables (religiosity, dogmatic religiosity, education level, socio-economic level, COVID-19 awareness) with vaccine hesitancy and their predictive levels were examined. The sample of the research consists of Muslim Turks over the age of 18. Participants were recruited using the convenience sampling method. The prepared online survey form was shared on social media platforms and the participants were reached. 322 Muslims between the ages of 18-70 (mean 30, SD=10.62) participated in the study. 65% of the participants are women and 55% are single. Ok Religious Attitude Scale, Dogmatic Religiosity Scale, Personal Information Form, COVID-19 Awareness Scale and Vaccine Hesitancy Scale were used as measures. Research findings showed that one-fifth of the participants did not receive the COVID-19 vaccine, half of them had 2 doses and the rest had different doses. Among the unvaccinated, the proportion of women and married people is higher. A negative correlation was found between age and vaccine hesitancy. While no relation could be found between education level and vaccination hesitancy, socio-economic level and vaccination hesitancy showed a negative correlation. When looking at other variables, it was found that there was no relationship between religiosity and vaccine hesitancy, but a negative relationship between COVID-19 awareness and vaccine hesitancy, and a positive relationship between religious dogmatism and vaccine hesitancy. Multiple regression analysis was performed to determine the predictive levels. In the multiple regression analysis, dogmatic religiosity, COVID-19 awareness and socio-economic level were added as a predictor, and vaccine hesitancy as an output variable. In the first step, only religious dogmatism was included in the model as a predictor. In step 3, three predictors were entered simultaneously. The findings showed that dogmatic religiosity, socio-economic status, and awareness of COVID-19 were significant predictors of vaccine hesitancy. In the first step, dogmatic religiosity alone accounts for about 3% of the variance in vaccine hesitancy. In the second step, dogmatic religiosity and socio-economic status together accounted for about 5% of the variance in vaccine hesitancy. And finally, in the third step, dogmatic religiosity, socio-economic level and awareness of COVID-19 together account for 7% of the variance in vaccine hesitancy. Considering the beta coefficients, it was seen that there was a positive correlation between dogmatic religiosity and vaccine hesitancy, and a negative correlation was found between vaccine hesitancy and socio-economic level and COVID-19 awareness. Considering the standardized regression coefficients, it is seen that the most important variable predicting vaccine hesitancy is dogmatic religiosity.

Promoting COVID-19 vaccination through music and drama-Lessons from early phase of the pandemic.

According to the World Health Organization, the coverage of vaccine-preventable diseases rests at 86% with nearly 20 million children worldwide who have not received basic vaccines. Vaccine-hesitant individuals are a heterogeneous group who hold varying degrees of indecision about specific vaccines or vaccination in general. Vaccine hesitancy is a behavior influenced by several factors including issues of confidence, complacency, and convenience. In countries where access is not the main issue for lack of vaccination, there are many cultural influences that affect the decision for parents to seek vaccination for their children or themselves. Media and social media can create a negative or positive vaccine sentiment and can provide a platform for lobbies and key opinion leaders to influence others. Community leaders and influencers, including religious leaders in some settings, celebrities in others, can all have a significant influence on vaccine acceptance or hesitancy. Vaccine mandates can provoke vaccine hesitancy not necessarily because of safety or other concerns, but due to resistance to the notion of forced vaccination. Lastly, the pharmaceutical industry may be distrusted and influence vaccine hesitancy when perceived as driven only by financial motives and not by public health interest. This can extend to distrust in government when perceived that it also is being pushed by industry and is not transparent. When working with patients faced with the decision of whether vaccination will be undertaken, it is imperative to understand the cultural, ethical, and legal implications that may affect their decision. Working from a place of understanding and acceptance of various views and beliefs about vaccination, nurses can be better advocates for the wishes of their patients.

Unpacking Vaccine Hesitancy Among Healthcare Providers

Background: The World Health Organization (WHO) warns that vaccine hesitancy is an ongoing major global health threat. While vaccination against severe acute respiratory syndrome coronavirus (SARS-CoV-2) proves to be an effective strategy in protecting against the disease, vaccine hesitancy represents a major barrier to stopping the spread of the virus. Willingness for vaccination can be influenced by several factors, including education level and health literacy. Although several studies demonstrate the value of video educational programs in improving coronavirus disease 2019 (COVID-19) vaccine knowledge and acceptance, no studies to date have evaluated if race, gender, and other demographic factors impact the influence of an educational video on COVID-19 vaccine knowledge and hesitancy among university students in the United States (U.S.). Aims: This study was conducted to determine the impact of an educational video on U.S. university undergraduate students’ COVID-19 vaccine perception and acceptance. It also aims to evaluate whether demographic factors affect the influence of the video. Methods: An online survey was used to measure perceived understanding and acceptance of COVID-19 vaccines before and after viewing a video regarding the effectiveness and safety of COVID-19 vaccinations. The impact of demographic factors on the Video Influence Score was analyzed. Key results: After viewing the video, respondents’ (n = 285) perceived awareness and acceptance of COVID-19 vaccines significantly increased (p < 0.05). In addition, gender, political party affiliation, age, study major, and influenza vaccination history did not significantly impact the Video Influence Score (p > 0.05). However, African American/Black respondents (3.81 ± 4.24) were significantly more influenced by the video compared to respondents of other races (p < 0.05), such as White/Caucasian (1.91 ± 3.75), Hispanic/Latino (0.17 ± 3.67), Asian (0.29 ± 1.53), and Indigenous American (0.64 ± 2.52). Conclusions: This study suggests the potential impact of an educational video on COVID-19 vaccine perception and acceptance among university students. Despite limitations such as a modest survey response rate, this study provides valuable insight concerning the influential factors affecting vaccine acceptance in diverse student populations. Future studies are warranted to explore how student response to vaccine educational videos may vary depending on students’ racial and cultural backgrounds. Implications: A targeted educational video to promote vaccine acceptance is a valuable tool for public health campaigns to combat vaccine hesitancy. The study also highlights the importance of tailoring interventions to specific demographic groups such as considering racial factors to maximize the impact of educational interventions on vaccine attitudes.

Objectives. To characterize COVID-19 vaccine uptake and hesitancy among US nurses. Methods. We surveyed nurses in 3 national cohorts during spring 2021. Participants who indicated that they did not plan to receive or were unsure whether they planned to receive the vaccine were considered vaccine hesitant. Results. Among 32 426 female current and former nurses, 93% had been or planned to be vaccinated. After adjustment for age, race/ethnicity, and occupational variables, vaccine hesitancy was associated with lower education, living in the South, and working in a group care or home health setting. Those who experienced COVID-19 deaths and those reporting personal or household vulnerability to COVID-19 were less likely to be hesitant. Having contracted COVID-19 doubled the risk of vaccine hesitancy (95% confidence interval [CI] = 1.85, 2.53). Reasons for hesitancy that were common among nurses who did not plan to receive the vaccine were religion/ethics, belief that the vaccine was ineffective, and lack of concern about COVID-19; those who were unsure often cited concerns regarding side effects or medical reasons or reported that they had had COVID-19. Conclusions. Vaccine hesitancy was unusual and stemmed from specific concerns. Public Health Implications. Targeted messaging and outreach might reduce vaccine hesitancy. (Am J Public Health. 2022;112(11):1620-1629. https://doi.org/10.2105/AJPH.2022.307050).

Background:Vaccine hesitancy can limit the benefits of available vaccines in halting the spread of COVID-19 pandemic. Previously published studies paid little attention to Arab countries, which has a population of over 440 million. In this study, we present the results of the first large-scale multinational study that measures vaccine hesitancy among Arab-speaking subjects.Methods:An online survey in Arabic was conducted from 14 January 2021 to 29 January 2021. It consisted of 17 questions capturing demographic data, acceptance of COVID-19 vaccine, attitudes toward the need for COVID-19 vaccination and associated health policies, and reasons for vaccination hesitancy. R software v.4.0.2 was used for data analysis and visualization.Results:The survey recruited 36,220 eligible participants (61.1% males, 38.9% females, mean age 32.6 ± 10.8 years) from all the 23 Arab countries and territories (83.4%) and 122 other countries (16.6%). Our analysis shows a significant rate of vaccine hesitancy among Arabs in and outside the Arab region (83% and 81%, respectively). The most cited reasons for hesitancy are concerns about side effects and distrust in health care policies, vaccine expedited production, published studies and vaccine producing companies. We also found that female participants, those who are 30–59 years old, those with no chronic diseases, those with lower level of academic education, and those who do not know the type of vaccine authorized in their countries are more hesitant to receive COVID-19 vaccination. On the other hand, participants who regularly receive the influenza vaccine, health care workers, and those from countries with higher rates of COVID-19 infections showed more vaccination willingness. Interactive representation of our results is posted on our project website at https://mainapp.shinyapps.io/CVHAA.Conclusions:Our results show higher vaccine hesitancy and refusal among Arab subjects, related mainly to distrust and concerns about side effects. Health authorities and Arab scientific community have to transparently address these concerns to improve vaccine acceptance.Funding:This study received no funding.

BackgroundVaccine hesitancy is a growing concern in Saudi Arabia, impacting even well-educated parents. The decision-making process involves various factors such as accessibility, trustworthy information, and the influence of social networks, reflecting a complex interplay of emotional, cultural, social, spiritual, and political dimensions.ObjectiveThis review seeks to evaluate the prevalence and trends of vaccine hesitancy, identify contributing factors, and explore potential solutions to enhance immunization rates. This review aligns with global concerns, as the World Health Organization has identified vaccine hesitancy as a top global health threat.MethodsOur systematic review will follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and PICOS (Population, Intervention, Comparison, Outcomes, and Study) criteria for comprehensive assessment. We will conduct a thorough search across various databases, encompassing a wide range of vaccines, and pay special attention to vaccination campaigns and refusals. Inclusion criteria involve descriptive, observational, and analytical studies focusing on factors influencing vaccine acceptance or hesitancy. The study will use the Crowe Critical Appraisal Tool for quality assessment and perform a narrative synthesis to summarize findings thematically.ResultsThis systematic review is expected to unveil the prevalence and trends of vaccine hesitancy in diverse populations in Saudi Arabia, shedding light on cultural, religious, and social factors contributing to hesitancy. It aims to assess the effectiveness of implemented strategies, enable regional and global comparisons, and provide implications for tailored vaccination policies. Additionally, the review may pinpoint research gaps, guiding future investigations to address and mitigate vaccine hesitancy effectively.ConclusionsThe findings are expected to have direct policy implications and guide interventions to strengthen vaccination programs and improve public health outcomes.International Registered Report Identifier (IRRID)PRR1-10.2196/54680

Vaccination remains one of the most effective public health interventions; however, recent global trends indicate a reversal in routine immunisation coverage alongside resurgent outbreaks of vaccine-preventable diseases. This review synthesises current evidence on declining immunisation coverage, the re-emergence of diseases such as measles and poliomyelitis, and the growing influence of vaccine hesitancy and misinformation on vaccine uptake. A systematic search of PubMed, Scopus, and WHO/UNICEF databases was conducted using terms including 'vaccine hesitancy', 'immunisation coverage', 'vaccine-preventable diseases', 'misinformation', and 'vaccine policy', covering literature published between 2000 and 2024. We examine how pandemic-related disruptions, structural inequities, and evolving information ecosystems have collectively weakened immunisation system resilience across diverse settings. Beyond epidemiological consequences, declining coverage reflects broader challenges related to trust, governance, and equity in vaccine delivery. The review highlights the limitations of reactive, outbreak-driven approaches and emphasises the central role of strong routine immunisation systems embedded within primary healthcare. We discuss policy implications for integrating behavioural and social science insights, strengthening risk communication, and advancing equity-oriented immunisation governance. We conclude that sustaining and extending global immunisation gains will depend on aligning scientific innovation with public trust and system resilience. Addressing vaccine confidence as a core component of immunisation performance is essential to safeguarding global health security in the coming decade.

Pediatric Vaccine Hesitancy and COVID-19