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Socio-Psychological Factors Driving Adult Vaccination: A Qualitative Study

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      While immunization is one of the most effective and successful public health interventions, there are still up to 30,000 deaths in major developed economies each year due to vaccine-preventable diseases, almost all in adults. In the UK, despite comparatively high vaccination rates among ≧65 s (73%) and, to a lesser extent, at-risk ≤65 s (52%) in 2013/2014, over 10,000 excess deaths were reported the previous influenza season. Adult tetanus vaccines are not routinely recommended in the UK, but may be overly administered. Social influences and risk-perceptions of diseases and vaccines are known to affect vaccine uptake. We aimed to explore the socio-psychological factors that drive adult vaccination in the UK, specifically influenza and tetanus, and to evaluate whether these factors are comparable between vaccines.


      20 in-depth, face-to-face interviews were conducted with members of the UK public who represented a range of socio-demographic characteristics associated with vaccination uptake. We employed qualitative interviewing approaches to reach a comprehensive understanding of the factors influencing adult vaccination decisions. Thematic analysis was used to analyze the data.


      Participants were classified according to their vaccination status as regular, intermittent and non-vaccinators for influenza, and preventative, injury-led, mixed (both preventative and injury-led) and as non-vaccinators for tetanus. We present our finding around five overarching themes: 1) perceived health and health behaviors; 2) knowledge; 3) vaccination influences; 4) disease appraisal; and 5) vaccination appraisal.


      The uptake of influenza and tetanus vaccines was largely driven by participants' risk perception of these diseases. The tetanus vaccine is perceived as safe and sufficiently tested, whereas the changing composition of the influenza vaccine is a cause of uncertainty and distrust. To maximize the public health impact of adult vaccines, policy should be better translated into high vaccination rates through evidence-based implementation approaches.

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      Most cited references 23

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      Qualitative research in health care. Analysing qualitative data.

       N Mays,  C Pope,  S Ziebland (2000)
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        Meta-analysis of the relationship between risk perception and health behavior: the example of vaccination.

        Risk perceptions are central to many health behavior theories. However, the relationship between risk perceptions and behavior, muddied by instances of inappropriate assessment and analysis, often looks weak. A meta-analysis of eligible studies assessing the bivariate association between adult vaccination and perceived likelihood, susceptibility, or severity was conducted. Thirty-four studies met inclusion criteria (N = 15,988). Risk likelihood (pooled r = .26), susceptibility (pooled r = .24), and severity (pooled r = .16) significantly predicted vaccination behavior. The risk perception-behavior relationship was larger for studies that were prospective, had higher quality risk measures, or had unskewed risk or behavior measures. The consistent relationships between risk perceptions and behavior, larger than suggested by prior meta-analyses, suggest that risk perceptions are rightly placed as core concepts in theories of health behavior. (c) 2007 APA, all rights reserved
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          Effect of neonatal circumcision on pain response during subsequent routine vaccination.

          Preliminary studies suggested that pain experienced by infants in the neonatal period may have long-lasting effects on future infant behaviour. The objectives of this study were to find out whether neonatal circumcision altered pain response at 4-month or 6-month vaccination compared with the response in uncircumcised infants, and whether pretreatment of circumcision pain with lidocaine-prilocaine cream (Emla) affects the subsequent vaccination response. We used a prospective cohort design to study 87 infants. The infants formed three groups--uncircumcised infants, and infants who had been randomly assigned Emla or placebo in a previous clinical trial to assess the efficacy of Emla cream as pretreatment for pain in neonatal circumcision. Infants were videotaped during vaccination done at the primary care physician's clinic. Videotapes were scored without knowledge of circumcision or treatment status by a research assistant who had been trained to measure infant facial action, cry duration, and visual analogue scale pain scores. Birth characteristics and infant characteristics at the time of vaccination, including age and temperament scores, did not differ significantly among groups. Multivariate ANOVA revealed a significant group effect (p < 0.001) in difference (vaccination minus baseline) values for percentage facial action, percentage cry time, and visual analogue scale pain scores. Univariate ANOVAs were significant for all outcome measures (p < 0.05): infants circumcised with placebo had higher difference scores than uncircumcised infants for percentage facial action (136.9 vs 77.5%), percentage cry duration (53.8 vs 24.7%), and visual analogue scale pain scores (5.1 vs 3.1 cm). There was a significant linear trend on all outcome measures, showing increasing pain scores from uncircumcised infants, to those circumcised with Emla, to those circumcised with placebo. Circumcised infants showed a stronger pain response to subsequent routine vaccination than uncircumcised infants. Among the circumcised group, preoperative treatment with Emla attenuated the pain response to vaccination. We recommend treatment to prevent neonatal circumcision pain.

            Author and article information

            [1 ]Faculty of Medicine, Imperial College London, London, United Kingdom
            [2 ]Sanofi Pasteur, Lyon, France
            [3 ]Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
            [4 ]Imperial College Business School, London, United Kingdom
            University of California Riverside, United States of America
            Author notes

            Competing Interests: AW and NS are funded by an unrestricted research grant from Sanofi Pasteur (P40006) and also by the UK National Institute for Health Research (NIHR), via the Imperial College's Patient Safety Translational Research Centre ( The fieldwork and associated research costs were funded by Sanofi Pasteur. AW and NS currently have a consultancy agreement as paid scientific advisors in the design of a shingles vaccine survey by Sanofi Pasteur MSD. BR and AT are employed by Sanofi Pasteur. The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health or Sanofi Pasteur. The funders do not have any editorial control over the work reported in this article. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or issues discussed in the manuscript, apart from those disclosed. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

            Conceived and designed the experiments: AW BR AT NS. Performed the experiments: AW. Analyzed the data: AW AP. Contributed reagents/materials/analysis tools: AW BR AT MM NS. Wrote the paper: AW AP BR AT MM CV NS.

            Role: Editor
            PLoS One
            PLoS ONE
            PLoS ONE
            Public Library of Science (San Francisco, USA )
            9 December 2014
            : 9
            : 12
            25490542 4260791 PONE-D-14-30108 10.1371/journal.pone.0113503

            This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

            Pages: 21
            The funder provided support in the form of salaries for authors [BR and AT], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the Author Contributions section.
            Research Article
            Biology and Life Sciences
            Cognitive Science
            Cognitive Psychology
            Attitudes (Psychology)
            Medicine and Health Sciences
            Infectious Diseases
            Bacterial Diseases
            Viral Diseases
            Social Sciences
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            The authors confirm that, for approved reasons, some access restrictions apply to the data underlying the findings. Data cannot be made publicly available due to ethical restrictions, but are available upon request from Ana Wheelock ( a.wheelock@ ).



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