The Importance of Confidence, Complacency, and Convenience for Influenza Vaccination among Key Risk Groups in Large Urban Areas of Peru

"The results highlight the importance of implementing in Peru communication strategies to increase perceptions of vaccine safety and effectiveness thus improving confidence and reducing complacency."

Influenza vaccination has been available under Peru's national immunisation programme since 2008, but vaccination coverage has decreased in recent years. In 2016, coverage was below 80% in at-risk groups and as low as 23% in pregnant women. This situation motivated the researchers to undertake an analysis of the barriers and drivers of influenza vaccine supply and demand and, in particular, the social factors affecting acceptance of influenza vaccination.

Vaccine hesitancy is the result of a complex interrelation of behavioural and societal factors whose intervention requires an integrated approach. Different conceptual models have been proposed to address the complexity, applicability, and potential usefulness of vaccine hesitancy indicators, as well as for the design of surveys and interventions that can be applied locally and globally. The "3Cs" model considered is one such model; it incorporates 3 categories for analysis: confidence (degree of trust in the effectiveness and safety of the vaccine, in the system that delivers vaccines, and in the motivations of policymakers who make decisions about vaccines), complacency (occurs when the risk of diseases preventable by vaccination is perceived as low), and convenience (refers to certain barriers, such as difficulty in accessing the vaccine).

The 3Cs model was used as a conceptual framework for the study, which was carried out in the cities of Lima and Arequipa, Peru, from October to December 2018. A 50-item questionnaire was administered, and focus groups were conducted, among 4 risk groups: pregnant women, mothers of children aged under 6 years, adults with risk factors (e.g., hypertension, gastritis, diabetes, cancer, chronic pulmonary diseases, and depression), and adults 65 years of age or older. In addition, interviews with programme officers were undertaken to identify efforts to improve access to influenza vaccine and the role played by strategies targeting vaccine uptake. For the analysis of supply-side factors, immunisation programme documents were reviewed, and officials involved in the national immunisation programme at the national decision-making level (strategic), as well as intermediate operators at the regional/local level (tactical), were interviewed.

Survey data summarised in Table 3 in the paper suggest low levels of knowledge about influenza and the vaccine across all risk groups. This table also summarises the results of the aggregated indices for the 3Cs. Of the 3 indices, convenience of the vaccine was the most favourable, with an overall value of 68.5%. Confidence in the vaccine was second with 64.6%, and complacency was third with 47.9%. There were no significant differences across risk groups for confidence. Two sets of risk groups showed mostly small but significant differences between them with respect to complacency and convenience, in the average of the 3Cs and in vaccination status: older adults and adults with risk factors, on the one hand, with lower values, and pregnant women and mothers, on the other, with higher values.

The 3 subcomponents of complacency showed important differences across them, with prejudices (side effects and reactions) and perception of risk of influenza ranking at about the same values, with between 52.4% and 53.3% for all risk groups, while knowledge of influenza and of the vaccine ranked lower, at 38.1%. No significant differences were observed across risk groups except for knowledge, with older adults scoring 31.2%, adults with risk factors 37.2%, and pregnant women and mothers scoring the highest, with 41.8% and 42.2%, respectively.

The 3 indexes were found to be significant in their relationship with the decision to be vaccinated in the last year in the total sample. The confidence index was significant only for older adults and pregnant women. The index of complacency was significant only for adults with risk factors, while convenience was significant for pregnant women and mothers. The odds ratios that represent the ratio-change in the odds of the event of interest (vaccinated) for a one-unit change in the indicator in each of the 3C are significant, which means means that a 10-percentage point increase in either indicator would result in expected increases in vaccination status of 10.4% to 11.7%.

In the focus groups, the risk groups expressed their perception of confidence in the influenza vaccine by sharing their views on vaccine effectiveness and safety (see Table 5). Relevant differences were observed between groups; for example, adults with risk factors had more - and more specific - doubts regarding vaccine safety. All 4 groups expressed a high level of convenience for getting vaccinated, especially because of vaccine availability. Mothers of minor children and pregnant women showed interest and concern for the welfare of their children or their future child. They attended health services on a regular basis during pregnancy and childcare, and they easily accepted and integrated the influenza vaccine as part of their routine care; however, a lack of clarity was observed in the role assigned to the influenza vaccine as a preventative measure vis-à-vis other preventative practices, such as a healthy diet.

The main barriers and opportunities identified by the personnel interviewed were related to strategic planning, coordination, implementation, and evaluation of the vaccination programme. Only 2 areas were identified as opportunities from the perspective of demand: strengthening community participation in communication and diffusion activities, and consolidating cooperation agreements between regional governments and public and private institutions.

In reflecting on the findings, the researchers point to the importance of promoting influenza vaccine confidence among the older population as well among the less educated. "To increase influenza vaccination coverage in this group, it is imperative to improve the regular access to health services and to provide more and better information. It would be recommendable to expand communication strategies taking advantage of the experience of other countries and regions, such as the social mobilization strategies implemented in Cameroon that were widely accepted by the population..."

Knowledge of the vaccine and influenza was found to be particularly weak in general, and it is the principal factor affecting complacency. While the importance of education has been widely discussed as a social determinant of health status, its role in the determination of each of the 3C components warrants further study, according to the researchers.

A key aspect noted in the literature is the sensitisation of health personnel toward the importance of the vaccine. The researchers assert that, in Peru, efforts along these lines, together with the strengthening of communication and dissemination strategies with an emphasis on risk groups and with an intercultural approach, could influence complacency and especially confidence. However, they stress that communication strategies must be precise to avoid counterproductive results that could lead to reinforcing vaccine hesitancy.

A review of the psychological and social factors affecting vaccination uptake has highlighted 3 groups of actions to consider for policy and programme development: changing what people think and feel about confidence in vaccine effectiveness and concerns about safety; improving normative messaging to bolster altruism in specific social contexts; and leveraging positive attitudes toward vaccination through incentives, sanctions, and requirements. Other recommendations include:

• Investigate the factors that affect the different risk groups to increase confidence and reduce complacency, particularly by improving information in relation to the disease and the benefits and safety of the vaccine.
• Strengthen information and communication campaigns, normative messaging, and performance incentives to focus on those aspects that affect confidence and complacency.
• Reduce missed opportunities for vaccination among elders and adults with risk factors.
• Apply the 3Cs model to investigate indecision in vaccine uptake among populations with greater barriers to the access of health services, as well as for lower socioeconomic groups, especially in rural areas of Peru.

In conclusion, the results of this study "suggest that the relative success in Peru with improving the convenience in influenza vaccine access has to be now followed-up with policies to address complacency and especially confidence through appropriate information on safety and effectiveness, through targeted messaging and particularly through performance incentives targeted to health personal and the population at large."