Testing persuasive messages about booster doses of COVID-19 vaccines on intention to vaccinate in Australian adults: A randomised controlled trial.

INTRODUCTION: Achieving high COVID-19 vaccine booster coverage is an ongoing global challenge. Health authorities need evidence about effective communication interventions to improve acceptance and uptake. This study aimed to test effects of persuasive messages about COVID-19 vaccine booster doses on intention to vaccinate amongst eligible adults in Australia. METHODS: In this online randomised controlled trial, adult participants received one of four intervention messages or a control message. The control message provided information about booster dose eligibility. Intervention messages added to the control message, each using a different persuasive strategy, including: emphasising personal health benefits of booster doses, community health benefits, non-health benefits, and personal agency in choosing vaccination. After the intervention, participants answered items about COVID-19 booster vaccine intention and beliefs. Intervention groups were compared to the control using tests of two proportions; differences of ≥5 percentage points were deemed clinically significant. A sub-group analysis was conducted among hesitant participants. RESULTS: Of the 487 consenting and randomised participants, 442 (90.8%) completed the experiment and were included in the analysis. Participants viewing messages emphasising non-health benefits had the highest intention compared to those who viewed the control message (percentage point diff: 9.0, 95% CI -0.8, 18.8, p = 0.071). Intention was even higher among hesitant individuals in this intervention group compared to the control group (percentage point diff: 15.6, 95% CI -6.0, 37.3, p = 0.150). Conversely, intention was lower among hesitant individuals who viewed messages emphasising personal agency compared to the control group (percentage point diff: -10.8, 95% CI -33.0, 11.4, p = 0.330), although evidence in support of these findings is weak. CONCLUSION: Health authorities should highlight non-health benefits to encourage COVID-19 vaccine booster uptake but use messages emphasising personal agency with caution. These findings can inform communication message development and strategies to improve COVID-19 vaccine booster uptake. Clinical trial registration: Registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622001404718); trial webpage: https://www.anzctr.org.au/ACTRN12622001404718.aspx.

Effect of persuasive messaging about COVID-19 vaccines for 5- to 11-year-old children on parent intention to vaccinate.

AIM: Uptake of COVID-19 vaccines for children aged 5-11 years old in Australia has plateaued. Persuasive messaging is an efficient and adaptable potential intervention to promote vaccine uptake, but evidence for its effectiveness is varied and dependent on context and cultural values. This study aimed to test persuasive messages to promote COVID-19 vaccines for children in Australia. METHODS: A parallel, online, randomised control experiment was conducted between 14 and 21 January 2022. Participants were Australian parents of a child aged 5-11 years who had not vaccinated their child with a COVID-19 vaccine. After providing demographic details and level of vaccine hesitancy, parents viewed either the control message or one of four intervention texts emphasising (i) personal health benefits; (ii) community health benefits; (iii) non-health benefits; or (iv) personal agency. The primary outcome was parents' intention to vaccinate their child. RESULTS: The analysis included 463 participants, of whom 58.7% (272/463) were hesitant about COVID-19 vaccines for children. Intention to vaccinate was higher in the community health (7.8%, 95% confidence interval (CI) -5.3% to 21.0%) and non-health (6.9%, 95% CI -6.4% to 20.3%) groups, and lower in the personal agency group (-3.9, 95% CI -17.7 to 9.9) compared to control, but these differences did not reach statistical significance. The effects of the messages among hesitant parents were similar to the overall study population. CONCLUSION: Short, text-based messages alone are unlikely to influence parental intention to vaccinate their child with the COVID-19 vaccine. Multiple strategies tailored for the target audience should also be utilised.

Exploring the lived experience of families with a COVID-19 positive child: The journey from a critical grounded theory approach.

COVID-19 and associated public health policies have significantly disrupted the lives of both adults and children. Experiences of COVID-positive adults are well described but less is known about the experiences of families of children who receive a positive diagnosis, and the impact of public health policies on this experience. This study aimed to develop a framework to understand the lived experience of families with a child testing positive for COVID-19. We applied a qualitative study design, using grounded theory. The study took place in Melbourne, Australia between July and December 2020, during the first major Australian COVID-19 wave. Parents of children 0-18 years tested at a walk-in clinic at a paediatric tertiary referral hospital were invited to participate. Two interviewers jointly undertook in-depth interviews with parents of children who tested positive. Interviews were transcribed and two analysts used an inductive, critical realist analysis approach with NVivo and a virtual whiteboard. Results are presented incorporating a stratified reality (empirical, actual, real). Families described seven sequential stages of the COVID-19 positive testing journey: COVID-19 close to home; time to be tested; waiting for the test result; receiving the result; dealing with the diagnosis; coping with isolation; and moving forward/looking back. Our findings highlight how public health policies and messages targeting the general (adult) public were experienced by families. We provide a framework that families move through when their child tests positive for COVID-19. Within each phase, we report unmet needs and identify strategies to improve future pandemic planning for parents and children.

Factors impacting COVID-19 vaccine decision making in older adults and people with underlying conditions in Victoria, Australia: A cross-sectional survey.

Australia's COVID-19 vaccine rollout included prioritizing older adults and those with underlying conditions. However, little was known around the factors impacting their decision to accept the vaccine. This study aimed to assess vaccine intentions, information needs, and preferences of people prioritized to receive the COVID-19 vaccine at the start of the Australian vaccine rollout. A cross-sectional online survey of people aged ≥70 years or 18-69 with chronic or underlying conditions was conducted between 12 February and 26 March 2021 in Victoria, Australia. The World Health Organization Behavioural and Social Drivers of COVID-19 vaccination framework and items informed the survey design and framing of results. Bivariate logistic regression was used to investigate the association between intention to accept a COVID-19 vaccine and demographic characteristics. In total, 1828 eligible people completed the survey. Intention to vaccinate was highest among those ≥70 years (89.6%, n = 824/920) versus those aged 18-69 years (83.8%, n = 761/908), with 91% (n = 1641/1803) of respondents agreeing that getting a COVID-19 vaccine was important to their health. Reported vaccine safety (aOR 1.4, 95% CI 1.1 to 1.8) and efficacy (aOR 1.9, 95% CI 1.5 to 2.3) were associated with intention to accept a COVID-19 vaccine. Concerns around serious illness, long-term effects, and insufficient vaccine testing were factors for not accepting a COVID-19 vaccine. Preferred communication methods included discussion with healthcare providers, with primary care providers identified as the most trusted information source. This study identified factors influencing the prioritized public's COVID-19 vaccine decision-making, including information preferences. These details can support future vaccination rollouts.

Vaccine Champions Training Program: Empowering Community Leaders to Advocate for COVID-19 Vaccines.

Strong community engagement has been critical to support COVID-19 vaccine uptake in Australia and elsewhere. Community engagement builds trust, enables tailored information dissemination and shapes social norms. Engagement is particularly important in communities with greater vaccine hesitancy, lower health literacy and mistrust in authorities. Early in 2021, as a team of vaccine social scientists and clinicians, we developed a program to train and empower community, faith, industry and healthcare leaders to advocate for COVID-19 vaccines as "vaccine champions". We partnered with the Victorian Department of Health to deliver 91 online Vaccine Champions sessions from March 2021 to June 2022. Over 80 people who received this training were supported by the Department of Health to become formal vaccine champions, independently delivering over 100 locally tailored information sessions. Our survey evaluation of 20 sessions delivered in 2022 found most participants (94%, 118/125) felt more confident to discuss safety and effectiveness of COVID-19 vaccines and find relevant information after attending a session. We also recorded >90% participant satisfaction with training content, format and presentation. Qualitative feedback from two group interviews highlighted the value of vaccine communication role plays and opportunities for discussion. In this brief report, we present an overview of the Vaccine Champions program, evaluation and next steps.

COVID-19 Vaccination in Pregnancy: Factors influencing uptake by women

Introduction COVID-19 infection in pregnancy is associated with increased morbidity and mortality for the mother as well as complications for the baby. In July 2021, the Australian Technical Advisory Group on Immunisation and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists recommended that pregnant women should be prioritised for COVID-19 vaccines and routinely offered Pfizer vaccine at any stage of pregnancy. There is no evidence on the pregnant women’s perceptions and acceptance of COVID-19 vaccine after this recommendation. Aim The aim of this research was to map COVID-19 vaccination in pregnancy acceptance, hesitancy and a change in original vaccination intentions. Methods A cross-sectional, anonymous, online survey was conducted in one area health service in New South Wales, including one large tertiary referral hospital and two smaller metropolitan hospitals. Descriptive analysis was done using SPSS. Results During September 2021 to January 2022, 1103 women responded to the survey and 1,026 completed the questions, with the completion rate of 93%. Women who did not complete the survey beyond demographics (8%) or were not pregnant (3%) were excluded. The mean age of the women was 33.3 years and most were either in their second (31%) or third (49%) trimester of pregnancy. Around half of the women were having their first pregnancy (51%) and born in Australia (47%). The majority of women agreed that COVID-19 vaccine was important for their health (84%) and important to protect others in the community (81%). Although 66% of women reported that at some stage they felt unsure about having the vaccine, the majority (87%) of women had at least one dose of vaccine. Conclusion This is the largest survey of pregnant women in Australia, providing evidence that acceptance of COVID-19 vaccination in pregnancy appears to be high among Australian women living in metropolitan areas.

The Pendulum Has Swung: How Do We Ensure a Life Course Approach to Immunisation in Australia?

Rather than concentrating primarily on children and adolescents, there has been a shift in the discourse around immunisation to encompass a whole-of-life approach. Despite this acknowledgement and ongoing high burdens of vaccine preventable diseases in adults, coverage for some adult risk groups remains sub-optimal. This study aimed to explore key informant's and stakeholder's perceptions of factors impacting provision of immunisation programs for Australian adults and to identify strategies to promote acceptance and uptake. Semi-structured telephone interviews were undertaken with people involved in adult immunisation program delivery, advocacy, policy or research between September 2020 and June 2021. Transcripts were inductively analysed, with the resulting themes categorised into the five influences on vaccination gaps that have informed program planning in other countries: Access, Affordability, Awareness, Acceptance and Activation. Participants spoke of improvements in the provision of vaccines to adults, however, ongoing challenges persisted. Participants agreed that the focus or emphasis of policies and the promotion/communication strategies has been on childhood vaccination in Australia, however there is a sense that the "pendulum has swung." These included understanding of eligibility amongst the Australian population and the reluctance of some health providers to dedicate time to exploring immunisation needs with adult patients. In comparison to the childhood vaccination program, there has been a lack of data available on coverage for adult vaccines on the national immunisation program. This has contributed to the ongoing challenges of identifying and promoting certain vaccines. At a government level, questions were raised about why the Australian government has never set an aspirational target for adult vaccination (i.e., influenza or pneumococcal) coverage. While significant improvements have been made in adult immunisation uptake, there are still gaps across the program. While the system remains under stress because of the COVID-19 pandemic, it is not appropriate to implement any additional programs. There needs to be strong commitment to establish the value of adult vaccination in the eyes of community members, policy makers and healthcare professionals. Having a national adult immunisation strategic plan would help advance action.

Intent to Be Vaccinated against COVID-19 in Victoria, Australia.

BACKGROUND: High vaccine uptake requires strong public support, acceptance, and willingness. METHODS: A longitudinal cohort study gathered survey data every four weeks between 1 October 2020 and 9 November 2021 in Victoria, Australia. Data were analysed for 686 participants aged 18 years and older. RESULTS: Vaccine intention in our cohort increased from 60% in October 2020 to 99% in November 2021. Vaccine intention increased in all demographics, but longitudinal trends in vaccine intention differed by age, employment as a healthcare worker, presence of children in the household, and highest qualification attained. Acceptance of vaccine mandates increased from 50% in October 2020 to 71% in November 2021. Acceptance of vaccine mandates increased in all age groups except 18-25 years; acceptance also varied by gender and highest qualification attained. The main reasons for not intending to be vaccinated included safety concerns, including blood clots, and vaccine efficacy. CONCLUSION: COVID-19 vaccination campaigns should be informed by understanding of the sociodemographic drivers of vaccine acceptance to enable socially and culturally relevant guidance and ensure equitable vaccine coverage. Vaccination policies should be applied judiciously to avoid polarisation.

Factors Influencing Australian Healthcare Workers' COVID-19 Vaccine Intentions across Settings: A Cross-Sectional Survey.

Healthcare workers' COVID-19 vaccination coverage is important for staff and patient safety, workforce capacity and patient uptake. We aimed to identify COVID-19 vaccine intentions, factors associated with uptake and information needs for healthcare workers in Victoria, Australia. We administered a cross-sectional online survey to healthcare workers in hospitals, primary care and aged or disability care settings (12 February-26 March 2021). The World Health Organization Behavioural and Social Drivers of COVID-19 vaccination framework informed survey design and framing of results. Binary regression results adjusted for demographics provide risk differences between those intending and not intending to accept a COVID-19 vaccine. In total, 3074 healthcare workers completed the survey. Primary care healthcare workers reported the highest intention to accept a COVID-19 vaccine (84%, 755/898), followed by hospital-based (77%, 1396/1811) and aged care workers (67%, 243/365). A higher proportion of aged care workers were concerned about passing COVID-19 to their patients compared to those working in primary care or hospitals. Only 25% felt they had sufficient information across five vaccine topics, but those with sufficient information had higher vaccine intentions. Approximately half thought vaccines should be mandated. Despite current high vaccine rates, our results remain relevant for booster programs and future vaccination rollouts.

Qualitative exploration of intentions, concerns and information needs of vaccine-hesitant adults initially prioritised to receive COVID-19 vaccines in Australia.

OBJECTIVE: Tailored communication is necessary to address COVID-19 vaccine hesitancy and increase uptake. We aimed to understand the information needs, perceived benefits and barriers to COVID-19 vaccination of people prioritised, but hesitant to receive the vaccine. METHOD: In this qualitative study in Victoria, Australia (February-May 2021), we purposively sampled hesitant adults who were health or aged/disability care workers (n=20), or adults aged 18-69 with comorbidities or aged ≥70 years ('prioritised adults'; n=19). We thematically analysed interviews inductively, then deductively organised themes within the World Health Organization Behavioural and Social Drivers of vaccination model. Two stakeholder workshops (n=12) explored understanding and preferences for communicating risks and benefits. We subsequently formed communication recommendations. RESULTS: Prioritised adults and health and aged care workers had short- and long-term safety concerns specific to personal circumstances, and felt like "guinea pigs". They saw vaccination as beneficial for individual and community protection and travel. Some health and aged care workers felt insufficiently informed to recommend vaccines, or viewed this as outside their scope of practice. Workshop participants requested interactive materials and transparency from spokespeople about uncertainty. Conclusions and public health implications: Eleven recommendations address communication content, delivery and context to increase uptake and acceptance of COVID-19 vaccines.

Parent-level barriers to uptake of childhood vaccination: a global overview of systematic reviews.

INTRODUCTION: Understanding barriers to childhood vaccination is crucial to inform effective interventions for maximising uptake. Published systematic reviews include different primary studies, producing varying lists of barriers. To make sense of this diverse body of literature, a comprehensive level of summary and synthesis is necessary. This overview of systematic reviews maps all potential parent-level barriers to childhood vaccination identified in systematic reviews. It synthesises these into a conceptual framework to inform development of a vaccine barriers assessment tool. METHODS: We applied Joanna Briggs methodology, searching the Epistemonikos review database and reference lists of included reviews to June 2020. Systematic reviews of qualitative or quantitative data on parent-level barriers to routine vaccination in preschool-aged children were included. Reviews addressing influenza, reporting non-modifiable determinants or reporting barriers not relevant to parents were excluded. Where possible, we extracted review details, barrier descriptions and the number, setting and design of primary studies. Two authors independently screened search results and inductively coded barrier descriptions. RESULTS: We screened 464 papers, identifying 30 relevant reviews with minimal overlap. Fourteen reviews included qualitative and quantitative primary studies, seven included quantitative and seven included qualitative studies only. Two did not report included study designs. Two-thirds of reviews (n=20; 67%) only included primary studies from high-income countries. We extracted 573 barrier descriptions and inductively coded these into 64 unique barriers in six overarching categories: (1) Access, (2) Clinic or Health System Barriers, (3) Concerns and Beliefs, (4) Health Perceptions and Experiences, (5) Knowledge and Information and (6) Social or Family Influence. CONCLUSIONS: A global overview of systematic reviews of parent-level barriers to childhood vaccine uptake identified 64 barriers to inform development of a new comprehensive survey instrument. This instrument will assess both access and acceptance barriers to more accurately diagnose the reasons for under-vaccination in children in different settings.

Minimising missed opportunities to promote and deliver immunization services to middle and older age adults: Can hospital-based programs be a solution?

BACKGROUND: There has been a recent recognized shift towards a whole-of-life or life-course approach to immunisation. However, coverage amongst at-risk adults for recommended vaccines continues to be suboptimal. This study examined the perceptions of middle and older aged Australian adults towards hospital-based immunization programs and their previous exposures to receiving vaccines via tertiary care. METHODS: A cross-sectional survey was conducted with Australian adults 45 years and older in late 2019 to capture influenza and pneumococcal vaccine uptake, exposure to hospital-based immunization programs, missed opportunities to vaccinate and receptiveness towards the promotion and/or delivery of vaccines in the hospital setting. RESULTS: Only 13 respondents reported receiving a vaccine at hospital, yet 72.2% (931/1292) indicated that they were willing to be vaccinated in that setting. Amongst those who attended hospital during 2019 and were eligible for vaccination, 57.2% and 28.3% of respondents were not immunized for pneumococcal and influenza, respectively. Missed opportunities for both vaccines were significantly higher amongst those at low-risk for influenza (≤65 years (low-risk): 52.9%, ≤65 years (high-risk): 18.3%, >65 years: 15.1%; p < 0.001) and pneumococcal (≤65 years (low-risk): 79.1%, ≤65 years (high-risk): 52.4%, >65 years: 44%; p < 0.001). Among those with a missed opportunity for hospital-based vaccination, the most common reason for not getting immunized was a lack of recommendation. Most (86.4%) reported that their general practitioner was the person or group they trusted most to receive vaccine information from. CONCLUSIONS: The findings from this Australian study support international work that shows very low rates of opportunistic vaccination in hospitals despite national recommendations to vaccinate prior to discharge. Considering the need for high levels of uptake of the COVID-19 vaccine, hospitals may need to be considered to opportunistically capture those not accessing the vaccine in other settings.

Preparing the public for COVID-19 vaccines

[...]as has been shown in previous mass vaccination programs, planning for vaccine program rollout and community engagement to optimise vaccine confidence and uptake in Australia needs to commence beforehand, not when the vaccines become available.5 Consistent with its existing role in vaccination programs, primary care professional are anticipated to play a key part in educating patients and carers about the vaccine, administering the vaccine, recording uptake and reporting adverse events following immunisation. There are currently 17 vaccines in phase I trials and 10 vaccines in phase II/III clinical trials (28 August 2020).6 Traditional vaccine development is a lengthy process, usually taking 10-15 years or more, with a distinct, linear sequence of steps and high attrition rate.7 The usual steps include pre-clinical development, safety testing (phase I), safety and immunogenicity testing (phase II) and then safety and efficacy testing (phase III), prior to licensure, production at scale and introduction into the population (Figure 1). Comprehensive post-marketing surveillance to track vaccine safety for these expected adverse events, as well as to detect postulated rarer adverse events such as antibody-enhanced disease, will also be essential to maintain vaccine confidence and achieve high vaccine acceptance and uptake. The WHO10 and the US Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunisation Practice (ACIP)11 are currently advising a risk- and aged-based approach for prioritisation of COVID-19 vaccine target groups.